Organizational Excellence Status of Iranian Hospitals with Emphasis on EFQM Model: A Meta-Analysis Study

Monitoring the performance of health care systems is a vital requirement for improving the quality of health care services. This review research was conducted on the results of recent studies in the field of organizational excellence in Iranian hospitals that were conducted with the EFQM model.

The current research was conducted in 2022 to review the articles published in Persian and English journals available in SID, Google Scholar, ProQuest, PubMed, Elsevier, ISI, Scopus, IranMedex, Science Direct, Spring, and CIVILICA related to the last 15 years. Articles were searched using the keywords of organizational excellence, performance assessment or evaluation, EFQM, hospital, and health system or their Persian equivalent. Information sources were analyzed based on qualitative analysis and meta-analysis using "Metafor version 3.8-1" and "Meta version 6.1-0" packages in the R programming language.

 In general, in the investigated period, 14 studies dealt with organizational excellence in hospitals, one of which was devoted to the qualitative study of organizational excellence and 13 to the quantitative evaluation of organizational excellence. Out of 13 studies, two studies were only limited to the evaluation of enablers. The articles' specifications and the quantitative results of organizational excellence components were presented (2006 to 2021) in Tables 2 and 3. Examining the time trend of studies shows that organizational excellence has not been a topic of interest to researchers in recent years, and no growing trend was observed in relation to the number of articles. Figure 2 is the forest diagram for the meta-analysis results of organizational excellence values on 13 studies. The overall estimate of the organizational excellence index for the mentioned studies was equal to 533 in the 95% confidence interval (464-602). In addition, the weight of each of the mentioned studies in the overall estimate of the analysis was reported as a percentage, and the two studies by Malekzadeh et al. [19] and Motaghi et al. [20] had the highest weight in the final result of this analysis with weights of 12.48 and 11.84, respectively (the large and bold square shape inside the confidence interval lines indicates the greater weight of that study). The index of organizational excellence in these studies varied between 367 and 700, and the range of changes based on random effects in the meta-analysis was estimated at 63%, indicating relatively significant changes among studies. This heterogeneity was also statistically significant (Q=37.5, P-value<0.001, I²=62.6%).The funnel diagram was used to check the publication bias in the meta-analysis in Figure 3. This graph shows that 3 of the 13 analyzed studies showed publication bias with 95% confidence and Egger's test (p-values <0.05). Notably, all three mentioned studies had a higher sample size than others, and the estimated effect in the two cases was lower and in one case was higher than the overall effect estimated in the meta-analysis. The score of the enablers dimension was equal to 500, therefore the index obtained for this dimension of organizational excellence in different studies was divided by 500 to obtain the desired effect size of the analysis as a ratio of the total score. Sixteen studies reported the enablers index score that was used for analysis. The total estimated value for enablers was equal to 276. Also, the amount of heterogeneity in the report of this index was estimated to be equal to 78%, which showed a statistically significant heterogeneity (p<0.001). Therefore, this heterogeneity in the report of the enablers index was evaluated as very severe (Figure 4). The score of the dimension of the results was equal to 500, therefore the index obtained for this dimension of organizational excellence in different studies was divided by 500 to obtain the desired effect size of the analysis as a ratio of the total score. Thirteen studies reported results index scores that were used for analysis. The total estimated value for the results was equal to 246. Also, the amount of heterogeneity in the report of this index was estimated to be 59%, which shows a statistically significant heterogeneity (p=0.001). Therefore, this heterogeneity in the results index report in different studies was evaluated at an average level (Figure 5). To investigate the publication bias in the enablers dimension report, according to the respective Funnel charts, the reports of 6 studies were beyond the range of 95% changes, which exactly the same 3 of the studies that showed the publication bias of the total organizational excellence index (Figure 4) were repeated in this list (Figure 6). To check the publication bias in the results dimension report, according to the relevant Funnel charts, only 3 studies were out of this range, which were exactly the same studies that had publication bias in the total organizational excellence index (Figure 7).

The state of organizational excellence in hospitals indicates the need to review the requirements for establishing clinical governance and accreditation systems, focusing on the dimensions of organizational excellence to improve the quality of healthcare services.