Evaluation of social accountability in hospital managers.

BACKGROUND: Today, hospitals need managers who, in addition to having the necessary skills for management and leadership, are accountable to stakeholders, especially the community. Accordingly, the purpose of this study was to evaluate the social accountability of managers of public and private hospitals in Tehran.
MATERIALS AND METHODS: The present study is descriptive-analytical and cross-sectional and was performed on 155 managers of selected public and private hospitals in Tehran. The research tools included a demographic characteristic questionnaire and a researcher-made social accountability questionnaire for managers. Data analysis was performed using descriptive and inferential statistics in SPSS 22 software.
RESULTS: The situation of social accountability in the managers of public hospitals was at a weak level and in the managers of private hospitals in Tehran was at a good level. In comparing the status of social accountability and its dimensions in the managers of public hospitals with the managers of private hospitals, the status of social accountability in the dimensions of human resource management, quality improvement, executive management, and overall social accountability were significantly different from each other (P ≤ 0.05). However, in terms of governance, the status of social accountability of public hospital managers was not significantly different from private hospitals (P ≥ 0.05). Overall, the results of social accountability in private hospitals were better than in public hospitals.
CONCLUSION: The social response status of managers in private hospitals was better than public ones. Lack of attention of managers to social accountability affects the quality of other educational, health, and medical services. This fact raises the need for managers to pay more attention to the issue of social accountability. Copyright:

Introduction

Management is the central core of performance improvement and productivity in organization and has a vital and strategic role for achieving these goals.[1] Therefore, high investment has been done, in industrial countries, in order to develop management abilities and skills.[2] The World Health Organization regards efficient management as the base of all effective health-related programs. It noted in its 2004 report that health system in most countries faced management inefficiency. This is known as an important obstacle against establishing Millennium Development Goals.[3] It was stated in the WHO annual report of the East Mediterranean region published in 2009 that hospitals are the significant and costly of health system all around the world and specified 50%–70% of governmental health budget to themselves. However, no considerable improvement has been seen in their performance.[4] As a result, one of the main factors contributing in developing hospital systems and the pivotally important agent in every organization is management.[5] Filler Mann and Porter stated that health systems lack qualified management in all countries and all levels of the system. In fact, they declared that the major problem is a management challenge rather than technology.[67] Consequently, management has a unique role in improvement of hospitals’ performance.[8] The responsibilities of hospital management toward society are beyond providing services for patients. This is known as the accountability to conduct effective measures for society and their responsiveness in the sake of these commitments.[9] Hence, one of the main essentialities of hospital management is social accountability.[10]

Social accountability refers to the potentiality of hospital managers to be responsible against pressures and society expectations. They should take strategies, styles, and regularities to assist them in this process. Therefore, it is clear that organization's structure and the capabilities of their managers have a significant role in hospitals’ social accountability.[11] The new concept of social accountability in organizations removes the conflicts related to social accountability to some extent. In the mentioned concept, ritualism is not the only factor in determining the responsibilities of organization and this issue has been tackled practically and the power of organization in handling social needs has been taken into consideration. Managers have a remarkable role in this new approach so that they try to find some ways to satisfy social problems before involving in social accountability.[12]

The managers should be familiar with social aspects of their profession and be informed of their organizational impact on social environment. Moreover, they should not be so self-absorbed with their own organization's goals and just focus on unnecessary details.[13] Based on scientific evidence, the improvement of social accountability brings considerable benefits for them. Some of these benefits are as follows: health-care cost decrease, reinforcement of social status and reputation of hospital, productivity promotion, absorption and maintenance of workforce, promotion of environment quality through prevention measures and controlling of pollution distribution, and improvement of energy consumption and resources in hospitals. The present evidence shows the correlation between responsiveness style of hospital management and clinical outcomes achieved from provided services in hospital.[14] In France, the hospitals with the best score of manager's accountability were very more successful in decreasing cesarean rate and also hospitalization duration rather than other centers. hospitals in Germany, Sweden, and the United States, which had the highest management accountability scores, also had the best clinical results[15] It was found in a study conducted in England a higher score in social accountability and management style lead to decrease 6.5% of mortality in emergency patients with myocardial infarction, 33% increase in revenue per bed and increase patients’ satisfaction.[16] Therefore, managers should take into consideration accountability and the rights of society members in the form of their own strategic programs. They are expected to focus on social accountability in addition to using their sociobiological and scientific capitals.[17]

Hospital managers can play an important role in providing efficient health care and respecting patients’ rights through social accountability toward patients and clients referring to hospitals. They can achieve their satisfaction and also promote social accountability concept. This study conducted to compare the situation of social accountability of managers working in governmental and private hospitals of Tehran city.

Materials and Methods

This descriptive-analytical study was conducted from February to August 2019 among the hospital managers of governmental and private hospitals in Tehran. The place of research included 7 and 5 governmental and private hospitals. The names of hospitals are not noted due to regarding confidentiality discipline. The samples consisted of 272 managers of governmental and private hospitals in Tehran. The sampling method was proportional allocation. Morgan table was used to determine the sample size. According to this table, out of 272 people in the statistical population, 155 people were selected as the research sample. The data collection instruments included demographic and managers’ social accountability questionnaires.

Demographic questionnaire

The information of this questionnaire consisted of the following items: gender, age, education major, education level, organizational position, and occupational history.

Managers’ social accountability questionnaire

It had four dimensions including governance, executive management, quality improvement, and human resource management. This questionnaire had 33 questions. Questions 1–6, 7–16, 17–22, and 23–33 were related to governance, executive management, quality improvement, and human resource management dimensions. Scoring in this questionnaire was based on Likert scale from 1 to 5 score. Very much, much, average, low, and very low were, in turn, specified with the score from 5 to 1. The score of every statement and the average score of every domain were measured between 0–5. For example, if the average achieved score was 2.5, it showed that accountability was weak. The score between 2.5 and 3.5 demonstrated an average level of accountability, and the average score more than 3.5 represented good accountability.

The validity of this questionnaire was confirmed by reviewing credible texts and scientific articles related to the research subject and also the viewpoints of expert managers. Content validity was used in the present study. The questionnaire was given to management experts. Then, they revised it, and the final manuscript was developed for the research.[11] The reliability of the questionnaire was confirmed by test–retest method. The questionnaire was completed by 20% of the studied samples in two episodes in 1-week interval. Cronbach's alpha was achieved 0.9. Involvement in the study and completing the questionnaire were absolutely volunteering with regard to ethical consideration. After describing the project's goals, the confidentialities of data was assured and verbal consent was achieved. The questionnaires were distributed anonymously. Data analysis was done by SPSS (version 22)(IBM, New York, United States) t hrough descriptive and deductive tests including mean, standard deviation, Levene's test, and t-test.

Results

It was reported that 155 managers involved in the study with 100% of answering. The results showed that 58.06 of the studied managers were males and 66.44% of them were between 40 and 60 years old. Furthermore, 45.16% of the samples had an undergraduate (B. Sc.) education level. Moreover, 54.19 of them were nurses. The results reported that 45.16% of the studied managers were clinical supervisors and 42.58% worked between 11 and 15 years in hospitals [Table 1].

Table 1

Demographic characteristics of the managers of the studied hospitals

Variable	Statistical indicators, frequency (%)
Gender
Male	90 (58.06)
Female	65 (41.93)
Age
<40	37 (23.87)
40-50	52 (33.54)
51-60	51 (32.90)
>60	15 (9.67)
Educational level
Undergraduate	70 (45.16)
Graduate	40 (25.80)
General doctor	8 (5.16)
Ph.D.	37 (23.87)
Field of study
Nurse	84 (54.19)
Management	18 (11.61)
General doctor	8 (5.16)
Specialist doctor	25 (16.12)
Post
Head of hospital	12 (7.74)
Hospital manager	37 (23.87)
Educational deputy	6 (3.87)
Research deputy	6 (3.87)
Nursing management	12 (7.74)
Educational supervisor	12 (7.74)
Clinical supervisor	70 (45.16)
Job history
1-5	6 (3.87)
6-10	14 (9.03)
11-15	66 (42.58)
16-20	54 (34.83)
>20	15 (9.67)

In the governmental hospitals studied in the present investigation, the mean scores of governance and human resource management were, in turn, 3.15 and 4.12 which were more than the expected mean score (2.5). T was supposed significant in error level <0.05 (P ≤ 0.05). Hence, it can be concluded that the achieved mean score was significantly different from the expected mean score. In other words, the social accountability of governmental hospitals’ managers was higher than the mean level in respect of governance and human resource management dimensions. They seemed to be in a good situation. However, the mean scores of the rest dimensions including executive management, quality improvement, and social accountability were 2.43, 2.37, and 2.14, respectively. They seemed to be less than the expected mean score (2.5). T was insignificant in error level more than 0.05 (P ≥ 0.05). It means that the achieved mean score was not different significantly with the expected score. Therefore, the social accountability of governmental hospitals’ managers was less than the average level in three noted dimensions. This means that their situation was poor [Table 2].

Table 2

Results of the total social accountability and its dimensions in public hospital managers

Variable	Paired difference					t	Degrees of freedom	Significance
	Experimental average (average obtained)	Theoretical average (expected average)	Mean difference	CI difference
				Minimum	Maximum
Governance	3.15	2.5	0.65	0.83	1.22	11.25	0.82	0.02
Executive management	2.43	2.5	0.07	0.71	1.05	13.12	0.82	0.06
Quality improvement	2.37	2.5	0.13	0.52	1.43	13.43	0.82	0.09
Human resource management	4.12	2.5	1.62	0.63	0.98	10.85	0.82	0.00
Total social accountability	2.14	2.5	0.36	0.58	0.91	12.62	0.82	0.12

In the studied private hospitals, the mean scores of governance, executive management, quality improvement, human resource management, and social accountability dimensions were, in turn, 3.98, 4.02, 4.13, 3.67, and 3.76, respectively. They seemed to be further than the expected mean score. T was supposed significant in error level <0.05 (P ≤ 0.05). It means that the achieved mean score was different significantly with the expected score. Therefore, the social accountability of private hospitals’ managers was higher than the mean score in governance, executive management, quality improvement, human resource management, and social accountability dimensions. It sounds to be in a good situation [Table 3].

Table 3

Results of the total social accountability and its dimensions in private hospital managers

Variable	Paired difference					t	Degrees of freedom	Significance
	Experimental average (average obtained)	Theoretical average (expected average)	Mean difference	CI difference
				Minimum	Maximum
Governance	3.98	2.5	1.48	3.14	4.58	72.53	59	0.00
Executive management	4.02	2.5	1.52	3.07	3.78	84.43	59	0.02
Quality improvement	4.13	2.5	1.63	3.26	3.47	71.36	59	0.01
Human resource management	3.67	2.5	1.17	3.15	3.53	68.66	59	0.00
Total social accountability	3.76	2.5	1.26	3.94	4.27	90.12	59	0.01

CI=Confidence interval

The results of Table 4 illustrate the comparison of total social accountability and its dimensions among both managers in governmental and private hospitals. Based on the results of Table 4, total social accountability and executive management, quality improvement, and human resource management in governmental and private hospitals were significantly different according to T in 0.05 level (P ≤ 0.05). In accordance with the results, total social accountability and executive management, quality improvement, and human resource management were significantly different in governmental hospitals rather than private hospitals. The comparison of achieved mean amounts showed that they were higher in private hospitals rather than governmental hospitals. The mean score of human resource management was the only dimension which was higher in governmental hospitals in comparison with private hospitals.

Table 4

Comparison of total social accountability and its dimensions in managers of public hospitals with managers of private hospitals

Variable	Hospital	Average	Levene’s test		Degrees of freedom	t	P
			F	Significant
Total social accountability	Public	2.14	16.73	0.00	0.68	115.74	0.041
	Private	3.76
Governance	Public	3.15	13.35	0.00	0.21	128.51	0.31
	Private	3.98
Executive management	Public	2.43	9.63	0.00	1.09	131.28	0.023
	Private	4.02
Quality improvement	Public	2.37	7.85	0.00	1.36	124.01	0.03
	Private	4.13
Human resource management	Public	4.12	10.92	0.00	0.93	135.66	0.01
	Private	3.67

In addition, no significant difference was reported in governance social accountability dimension of managers in the studied governmental hospitals in comparison with private hospitals with regard to T in 0.05 level (P ≥ 0.05). Therefore, it can be concluded that the social accountability of managers in the studied governmental hospitals and private hospitals in the dimensions of governance was not different significantly. The comparison of the achieved mean scores showed that it was further than the average level for both types of studied hospitals [Table 4].

Discussion

The goal of this study was to compare the social accountability of managers working in governmental and private hospitals in Tehran.

The results of the present investigation showed that social accountability was in a good situation in respect of governance and human resource management dimensions. Nevertheless, the situation of social accountability and executive management and quality improvement dimensions were poor. Vejdani et al.[18] conducted an investigation with regard to social accountability in providing health care in respect of patients’ experiences in governmental hospitals of Sabzevar city. They found that total social accountability in the studied hospitals was achieved 2.43 out of maximum score.[4] This represented that social accountability was in average level which was higher than the present study's result. Nasiripour et al.[19] investigated social accountability in educational hospitals of Iran from staff's points of view. Social accountability was higher than the average level (3.01 out of 5) in this research which is not in line with the results achieved in the present study. They stated that cultural, financial, legal, structural, informational, functional, ethical, and political dimensions impact social accountability in hospitals. They also suggested establishing a single office as the responding unit with scientific approach. This office reinforces the foundations of responding improvement in hospitals by strategic programs based on every region's cultural and demographic characteristics. Moradifard et al.[20] showed in their study that social accountability in their studied hospitals was in average level in according to the viewpoints of staff. This means that organizations should promote their goals, roles, working processes, communication, and rewards. The improvement of organizational atmosphere can lead to progress social accountability. Goodman et al.[21] defined social accountability as a strong alternative for developing justice and health-care services. They studied social accountability in health care in western and central parts of Africa in 2017. The researchers noted the role of health facility committees in social accountability of health services. They stated that the success of social accountability depends on management and leadership on health committees and suitable cooperation with other society and health system structures. Meanwhile, lack of rewards for staff results in reducing occupational motivation, occupational commitment, and inconsistency in interactions and interpersonal communication. All of these factors impact social accountability. They, consequently, suggested establishing an institute or social accountability system with structured and flexible framework which can be developed in the future.

All the results of the reviewed studies were higher and better rather than the present investigation's findings. The reasons of this difference were as follows: proper organizational atmosphere, effective management and leadership, sufficient cooperation with other structures of health system, and the impact of cultural, financial, structural, functional, and ethical dimensions on social accountability. The reasons of weakness in the present study's results in comparison with previous studies can be as follows: lack of governmental hospitals managers’ attention to social needs and challenges of stakeholders such as patients and society and also ignorance of economic, social, and environmental impacts of weak accountability. Holding seminars, gatherings, and question and answer sessions with the stakeholders can be an alternative to respond to society's social challenges. This is done through explaining the importance of this issue to them and prioritizing their needs.

Governance, executive management, quality improvement, human resource management, and total social accountability were in a good situation in Tehran's private hospitals in the present research. Arab et al.[22] studied the social accountability of Tehran's private hospitals from hospitalized and outpatient clients’ viewpoints. Their results showed that social accountability in these hospitals was in the upper average level based on the patients’ points of view. Hospitalized patients considered total social accountability higher in comparison with outpatient clients. This is in line with the findings of the present investigation. This difference can be due to the policies of the Health Ministry to improve the quality of hospitalization services. This also attributes to the increase of patients’ hospitalization and enhancing their awareness of staff activities and establishing sufficient communication between staff and patients. This process can be lead to more accountability and forming more positive attitude of patients toward staff and hospital. Hooshmand et al.[23] studied the social accountability of private hospitals in Mashhad city based on the hospitalized patient's interviews. Total social accountability and its dimensions were in average level and less than the results of the present investigation. The researchers attributed these findings to the limitation of budgets which the managers in the private hospitals face with. They suggested removing the barriers and promoting social accountability in organization based on the present performance gaps and their importance. They also recommended the following alternatives to improve social accountability: providing instruction and checklist of proper social accountability, establishing accountability unit or office with new approach, designing and performing scientific rounds with regard to social accountability in different aspects for managers and staff, and also episodic assessment of hospitals in order to measure their social accountability. Javadi et al.[24] conducted an investigation with regard to organizational justice and social accountability in private hospitals in Isfahan city. The score of social accountability was higher from patients’ viewpoints rather than nurses and seemed to be good. It was accompanied by the present research. The existence of a relationship between organizational justice and social accountability indicates that justice in an organization and in fact what employees perceive in the organizational procedures of the behavior and performance of managers has a great impact on their behavior and performance with patients. This, finally, affects the social accountability of staff, managers, and hospital. This reality necessitates the importance of manager's concentration on justice, human capital, motivators, the mechanisms for more qualified accountability, and providing more sufficient services.

The findings of the present investigation were similar to Javadi et al.'s and Arab et al.'s studies. The reasons for this similarities include the following items: the relation between staff and patients, providing high-quality services for patients, taking care of the patients more efficiently as a source of income, higher level of organizational justice in private hospitals rather than governmental ones, the presence of motivational mechanisms such as extra work, and personal, familial, and financial facilities such as loans without interest.

There were significant differences among the dimensions of social accountability including total social accountability, executive management, quality improvement, and human resource management in the present investigation (P ≤ 0.05). The mean scores of the mentioned dimensions indicated that social accountability in private hospitals was higher in comparison with governmental ones. Nevertheless, social accountability in governance dimension was not shown any significant difference between two types of hospitals in the present investigation (P ≥ 0.05). In general, the situation of social accountability in private hospitals was better than governmental ones.

Gharaee et al.[25] conducted a study in which the social accountability of two types of hospitals was assessed in Yazd city. The mean scores of the achieved results showed that there was a significant difference between them in respect of social accountability so that this factor was higher in private hospital rather than governmental ones. This is consistent with the present study findings. The reasons of their similarities include taking policies such as methods and payment mechanism revision, allocation of results to staff, reassessment of decision-making processes, and also improvement of the relation between managers and staff. All of them lead to increase the social accountability in private hospitals.

Sajjadeh[26] found that accountability was higher in private hospitals rather than governmental ones in the studied hospitals in Shiraz city. This is in line with the results of the present investigation. Liabsuetrakul et al.[27] compared the performance of hospitals in both types of hospitals in Thailand. They found that social accountability was higher in private hospitals rather than governmental ones. Hooshmand et al.[23] found the same results. Disregarding the social accountability can affect the quality of other health services. On the other hand, this concept should be regarded seriously in hospitals. Karoo et al.[28] defined social accountability as the respect to patient dignity. Hence, it should be taken into consideration increasingly as a basic concept in medicine. Griffith[29] conducted a study with this title: accountability for better managing treatment services, reorienting and revising Care Quality Commission (CQC) in hospitals. He focuses on legal and ethical aspects of accountability to reinforce this concept from legal and professional dimensions. As a result, social accountability as a spiritual task based on values and ethical criteria is defined as one of the main managers’ and staff's responsibilities so that they should follow professional standards of skills in order to provide accountability for stakeholders.

The results of the present study are similar to the findings of the mentioned investigations. The reasons of these similarities are as follows: valuing more staffs work in private hospitals rather than governmental ones, improvement of relation between staff and managers in private hospitals, mechanism of payment so that financial motivations are limited in governmental hospitals and they pay mostly fixed payment, and poor monitoring or negligence in conducting performances in governmental hospitals. All these factors result in degrading the importance of social accountability.

Limitation of the study

The limitation of this study is as follows: the population of this research was limited. Hence, the generalization of results to other samples should be done restrictedly. Since the scores of social accountability of managers in governmental and private hospitals are different with the score in the whole society, the generalization of the findings to the managers of other Tehran hospitals and the hospitals’ managers in Iran cannot be done with high assurance.

Conclusion

The results of the present study showed that the scores of social accountability of private hospitals were higher than their counterparts in governmental sector in Tehran city. Basically, most people refer to governmental hospitals in order to receive health services. This is also supposed that these hospitals have lower quality, whereas facilities, skilled human forces, clinics, and admission wards of governmental hospitals are further, and they own more advanced facilities and higher budget than private hospitals. These advantages permit governmental hospitals to achieve the potential to provide safer health services with higher quality to the patients and society. The managers of governmental hospitals are expected to bring about strategies for supplying high-quality health care with further social accountability using their own strategic capitals. They also should consider ethical aspects and social needs in their decision-making process. These managers can be the model of their staff by showing accountability with regard to their responsibilities. This leads to resolute social problems and increases respect and faithfulness in other managers and staff.

Financial support and sponsorship

This research was conducted with the financial support of the Vice-Chancellor for Research and Technology of Iran University of Medical Sciences and Health Services.

Conflicts of interest

There are no conflicts of interest.