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. 2023 Aug 30;37:94. doi: 10.47176/mjiri.37.94

Factors Affecting the Good Governance in Teaching Hospitals: A Narrative Review

Ali Javani 1, Akhtar Jamali 1,*, Nader Gholi Ghoorchian 1
PMCID: PMC10657255  PMID: 38021394

Abstract

Background

One of the indicators of development in different countries is the efficiency of the health care system. Hospitals and health centers have a very important role in the sustainability of society as w well as its economic growth and development. Meanwhile, one of the important development indicators of hospitals is good governance. This study was aimed to determine the factors affecting good governance in teaching hospitals.

Methods

This study was a scoping review of Iranian databases, including IranDoc, ISD, Magiran and International databases such as Science Direct, ISI, PubMed and Scopus to meet the good governance factors in teaching hospitals. There were no time limitations to data collection. the keywords governance, good governance, hospital governance, and good governance in hospitals, teaching hospitals, hospital management, hospital leadership, and their synonyms were used in the search strategy. The content analysis method was used to analyze selected studies.

Results

The findings showed that the characteristics of effective governance in teaching hospitals can be considered as follow: efficiency, managing conflict of interests, facilitated operation, managed and under control activities, integration, and synergy, achieving the desired consequences, creating an atmosphere that is rewarding and for each member.

Conclusion

Based on the results regarding the good governance model in teaching hospitals, it is recommended that on the basis of the nature of service, the mission and value of teaching hospitals have to be clearly redefined. On the other hand, the methods based on which we treat patients should be seriously redefined and we should pay more attention to the patient's values because the patients feel that we are practicing and testing them.

Keywords: Good Governance, Educational Hospitals, Patients

↑What is “already known” in this topic:

The good governance of the hospital makes it play a better role in the society. Achieving universal health coverage is only possible through proper administration and the connection of the hospital with other parts of the society.

→What this article adds:

This article illustrates what are the factors influencing good governance in teaching hospitals and how to move towards good governance.

Introduction

Modern organizations, including hospitals, with traditional structures must have the necessary flexibility to compete in the global business environment in order to effectively respond to continuous changes or eliminate them (1, 2). From a systemic perspective, an organization cannot be examined without considering its interaction with its external environment. In fact, organizations have an inseparable link with their external environment, and external changes and developments will strongly impact their functions, performance, and internal structure. Therefore, interaction with the external environment becomes a necessity for organizations, enabling them to secure vital and necessary resources (3). Among these, the hospital environment is one of the most interactive work environments, involving interactions between nurses and patients, nurses and doctors, and doctors and patients, presenting more challenges compared to other organizations (4).

Fillerman states in his study that healthcare systems worldwide, at all levels, face a lack of management and development, and the development of these organizations should be addressed (5). Therefore, managerial weaknesses and lack of necessary information for effective decision-making contribute to poor control and weak organization, including inefficiencies in hospitals. Since the most important task of managers is timely decision-making, this can only be achieved when sufficient information on the subject matter is available and influential factors in organizational development are identified and pursued (6). Hospitals continuously face challenges from internal and external environmental forces such as demographic changes, the use of new and expensive technologies, changes in the healthcare market, economic conditions, and reforms in healthcare systems (7). These changes and advancements present challenges for managing these organizations and emphasize the need for renewal and attention to this system (8). Meanwhile, service sectors today play a significant role in economic growth and higher quality standards of people's lives, and without considering the service sectors, the development of other sectors is not possible (9). Therefore, managerial and governance weaknesses in current conditions can exacerbate existing challenges more than in the past.

The topic of organizational changes and structural reorganization is an ongoing issue in the context of transformation. Managerial shifts, position changes, systematic rearrangement, and even the increase or decrease of certain organizational branches in terms of changing responsibilities or delegating some organizational responsibilities to others, or transferring some new tasks to the organization provide the grounds for organizational changes and structuring. Over time, these factors can be subject to change due to the transformation and evolution of needs, desires, and ultimately demands. Such changes require proper governance. However, change is one of the most fundamental topics in organizations. The formation and organization of an organization responsible for providing services related to human health are no exception to this rule. What matters is the purposefulness of each organization and its future movement towards goals and continuous control in terms of targeted movement and the preservation and improvement of service quality (10).

The issue of governance in teaching hospitals should receive attention from healthcare managers and policymakers for two reasons. Firstly, due to the governmental nature of teaching hospitals, which serve a large segment of the population who demand access to their facilities. And secondly, considering their mission to facilitate the education of a significant number of students, the desired quality of education and medical treatment in these hospitals can play a crucial role in advancing the knowledge of medical and paramedical graduates, ultimately benefiting the health of patients. These matters underscore the increasing need to focus on governance in the educational structure of the healthcare sector more than ever before.

Governance theories have been proposed as alternatives to public management theory in the current changing world, and its three major schools of thought are good governance, public governance, and corporate governance (11). Good governance is a concept consisting of criteria and standards, procedures, and principles of managing organizations and governments through which public affairs are conducted, and public resources are managed. Transparency, accountability, responsiveness, participation, rule of law, and flexibility can be considered important pillars of good governance. Good governance has a close relationship with the principles of people's participation in decision-making processes, in other words, it is a set of practical criteria and indicators of systems in procedural, structural, and substantive dimensions (12).

Experiences of different countries in hospital governance can be formulated and utilized, but there is no specific model in the field of teaching hospitals. Lack of integration of the governance process and its boundaries of influence are among these shortcomings. Some domestic and foreign studies have also emphasized the need for these interventions, and part of it has been studied by analyzing the relationship with collaborating centers. However, there is no comprehensive research that evaluates the model of good governance in teaching hospitals. In this regard, the present study was conducted to identify the influential factors on good governance in teaching hospitals.

Methods

Type of Research

The scoping review method was used to determine the factors affecting good governance in teaching hospitals (13).

Inclusion criteria

We reviewed the qualified articles, reports, and theses related to good governance in hospitals that could be checked through searching or referring to libraries and on the basis of these inclusion criteria: to be up-to-date (2000 onwards), relevant (all articles that were done regarding good governance in various fields, especially health and treatment) and authentic and scientific and the language Persian or English.

Search strategy

All articles, papers, reports, and dissertations with Persian as well as English language keywords including governance, good governance, hospital governance, good governance in hospital, teaching hospitals, hospital management, Hospital Management Leadership in the hospital and their synonyms were used to search in Science Direct, ISI, PubMed and Scopus as well as Iranian IranDoc, SID, Magiran databases.

Review articles

The titles of selected articles and texts were studied. Therefore, the topics that matched the subject of the study were selected, and their abstracts were also studied. Then, articles that had both titles and abstracts related to the research topic were selected, their full text was studied, and Information was organized and tabulated in data charting forms.

Analysis

The data was analyzed based on content analysis. After reviewing the texts and analyzing the content of the codes reported in the articles, they were categorized, and finally, the main theme was extracted from them.

Results

Components and indicators of good governance have been examined in various articles. One common model in good governance is the components that influence good governance in the United Nations, which include 8 components: participation, rule of law, transparency, accountability, consensus orientation, equity and inclusiveness, responsiveness, and efficiency and effectiveness.

The World Bank defines good governance based on six indicators (Figure 1), which are: the indicator of voice and accountability, the indicator of political stability, the indicator of government effectiveness and efficiency, the indicator of the quality of laws and regulations, the indicator of rule of law, and the indicator of control of corruption. The sub-themes of this model are presented in Table 1.

Figure 1.

Conceptual model of good governance in teaching hospitals (Kaufmann D., Kraay, A. and Mastruzzi M. (2010); "The Worldwide Governance Indicators: Methodology and Analytical Issues", Available at: www.govindicators.org).

Figure 1

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Table 1. Good governance dimensions and sub-dimensions.

Dimension Sub- dimension
Voice and Accountability Improving government performance
Creating political stability
Physical capital accumulation
Human capital accumulation
Political Stability Increase domestic and foreign investment
Preventing the brain drain
Government Efficiency Suitable structures, the proper size and decently sufficient payments
Responsible, professional and free of corruption
Independent, responsible and representative
Regulatory Quality Transparency
Equalizing Opportunities
Timely legal system
Rule of Law Protection of property rights and good performance of contracts
Market development
Entrepreneurship
Control of Corruption Inefficient allocation of human capital
Corruption as a barrier to Entering the market
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Based on review studies good governance indicators are presented in Table 2.

Table 2. Key indicators of good governance.

Key indicators of good governance Reference
The effectiveness of new public management Osborn & Gaebler,1992 (14)
government effectiveness in various forms of intervention in the public sector Gray, 1994 (15); Rhodes, 1994 (16)
The ability of the socio-political system to manage and resolve conflicts Commission on Global Governance, 1995 (17)
Political stability, Protest, and accountability, Government effectiveness, The rule of law, Regulatory quality Kaufmann, Kraay, & Zoido-Lobatón, 1999 (18)
Protest and accountability, Government effectiveness, Regulatory quality, The rule of law Neumayer, 2002 (19)
The role of government in solving social problems Kooiman, 2003 (20)
A process that implies different actors such as the government, business, and urban society in line with the general desire to solve social problems. Klijn, 2008 (21)
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Studies on good governance in hospitals have shown that these indicators in the hospital sector include decision-making structure, responsiveness structure, budget allocation structure, personnel and financial claims structure, policy structure, and market interaction structure, which are presented in Table 3.

Table 3. Themes and sub-themes of good governance in a teaching hospital.

Article Theme Comprehensive theme Theme Sub-them
Decision structure Council decision Relative independence in domestic decision-making Relative independence in financial decisions
Relative independence in human resource decisions
Relative independence in trading decisions
Multidimensional decision structure Three-level decision-making structure
Designing the Board of Trusteesstructure
Rational choice of hospital CEO
Establish a board of directors
Response structure Comprehensive responsibility Centralized dual decision structure Independence monitoring
Simultaneous application of budget control and functional control
Design performance criteria
The decentralized multifaceted accountability structure Response system
Three-level responsibility
Budget allocation structure Strategic budget Planned budget allocation Allocate overall performance budget
Budget allocation at the micro level
Change the budget approach reduce dependence on the government budget
Freedom of action for strategic actions
Design a payment system for staff
The structure of social performance-related policies Constructive interaction with society Development of social services Strengthen insurance participation
Development of private services Design a mechanism for health sector participation in the community
Freedom of action in privatization
The structure of the market interaction Freedom of action in interaction with the market Relative freedom of action in the development of the service market Establish a relationship between income and expenditures
Establish a relationship between service delivery volume and personnel income
Relative freedom of action in the development of the goods market Freedom of action in outsourcing
Establish a relationship between hospitals and markets
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Therefore, based on the review of studies, the characteristics of effective governance in teaching hospitals can be summarized as follows: efficiency, accepting conflicts of opinions/perspectives, ease of performance, measured actions, coherence, and synergy, achieving desired outcomes, protecting collective interests, creating a conducive environment, and providing individual rewards for each member. Accordingly, the pattern of good governance in teaching hospitals can be as follows.

Discussion

The results of assessing the healthcare system status in different countries indicate that these countries are striving to transform and improve the delivery of care. Hospitals, in particular, are considered a focal point for providing these services, and it is important to examine their role as the primary centers of care from various aspects (22). However, an overview of the current situation of hospitals in the country shows that many of them are facing increased demand, overcrowding, and patient dissatisfaction regarding access to services and their quality. It is worth noting that the construction, establishment, and management of hospitals are costly, with heavy initial investment expenses (23). Therefore, investigating the factors that affect good governance in teaching hospitals is of great importance. Among the influential factors in good governance, the most important aspect of hospital governance is considering all factors related to the customer (patient). The significance of understanding the recipients of the service lies in the fact that the information obtained through studying service recipients is a successful method for strategic evaluations and the development of healthcare services (24). In fact, patient satisfaction in healthcare organizations has been recognized as a key indicator associated with efficiency in such organizations (25), and it can be seen as the recipient's response to the services provided, reflecting their overall perception of service quality (26). Furthermore, satisfaction is important because it encourages customer participation in the process of care and treatment (27). Therefore, responsible healthcare organizations require the adoption and implementation of programs aimed at improving services for their survival and success, leading to improved patient satisfaction (28, 29). Paying attention to the needs of service recipients and respecting their rights significantly advances the development of hospitals.

The structure of market interaction through the establishment of an income-cost relationship is also considered one of the factors influencing good governance in hospitals. Various studies have identified favorable economic conditions as an important factor in the development of hospitals. In this regard, Jenkins and Merley (30, 31) and other studies have identified household income and per capita income as important components of the economic situation (32-34).

The structure of policies related to social performance and justice in health is also among the influential factors in good governance. Rashed also highlights in his study that nowadays, justice in health and addressing injustice in the health sector have become one of the most important concerns of health systems worldwide, especially in developing countries (35). Grille also considers issues related to justice in health as noteworthy points and ongoing concerns for researchers, planners, and policymakers in the field of health (36). In this regard, the World Health Organization emphasizes the need to measure justice in resource distribution, as considering access to health services as a fundamental right for all individuals leads to inequalities in the geographical distribution of health resources, posing challenges to people's access to these services (37). However, paying attention to socially vulnerable groups during the assessment of social needs and establishing compensatory mechanisms to address the health problems of individuals with inadequate health status is of great importance (38).

The budget allocation structure and personnel and financial demands are also among the important factors and rising expenditures cause cost crisis and create challenges on resource allocation and budgeting. In Lux's study, good doctors and staff have been identified as contributing factors to the development of hospitals (39). Other studies have mentioned advanced equipment and specialized facilities and characteristic of personality as important factors for the improvement and development of hospitals (34, 40, 41, 42, 43, 44).

Conclusion

Based on the results in various areas of good governance development in teaching hospitals, it is recommended that the development of hospitals primarily focus on understanding the needs of service recipients and aligning towards values that are important for patients. Since patients are considered a tool for education in teaching hospitals, preserving patient values should be given special attention in the dimensions of good governance while ensuring they receive sufficient and appropriate services. Healthcare organizations should increasingly value service recipients and their safety and dignity. Providing suitable infrastructure and potentials in various areas of teaching hospital development is suggested, which can serve as a suitable tangible model for other non-teaching hospitals and ultimately contribute to improving community health.

Conflict of Interests

The authors declare that they have no competing interests.

Cite this article as : Javani A, Jamali A, Ghoorchian NG. Factors Affecting the Good Governance in Teaching Hospitals: A Narrative Review. Med J Islam Repub Iran. 2023 (30 Aug);37:94. https://doi.org/10.47176/mjiri.37.94

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