Skip to main content

Developing a quality and safety assessment framework for Iran’s military hospitals



The first crucial step towards military hospitals performance improvement is to develop a local and scientific tool to assess quality and safety based on the context and aims of military hospitals. This study introduces a Quality and Safety Assessment Framework (Q&SAF) for Iran’s military hospitals.


This is a literature review which continued with a qualitative study. The Q&SAF for Iran’s military hospitals was developed initially, through a review of the WHO’s framework for hospital performance, literature review (other related framework), review of military hospital-related local documents, consultations with a national and sub-national expert. Finally, the Delphi technique used to finalize the framework.


Based on the literature review results; 13 hospital Q&SAF were identified. After reviewing literature review results and expert opinions; Iran’s military hospitals Q&SAF was developed with 58 indictors in five dimensions including clinical effectiveness, safety, efficiency, patient-centeredness, and Responsive Management (Command and Control). The efficiency dimension had the highest number of indictors (19 indictors), whereas the patient-centered dimension had the lowest number of indices (4 indictors).


Regarding the comprehensiveness of the developed assessment framework due to its focus on the majority of quality dimensions and important components of the hospital’s performance, it can be used as a useful tool for assessing and continuously improving the quality of hospitals, particularly military hospitals.

Peer Review reports


Military healthcare structures, particularly military hospitals, play an important role in achieving the health system’s goals and responding to the population health needs by supporting and providing medical services to the armed forces in military operations as well as assisting the civilian healthcare system [1].

In the hospital, due to the importance of services and dealing with human lives, quality assurance and improvement have become increasingly crucial [2]. Quality is a broad and multifaceted concept including technical competence, access to services, effectiveness, interpersonal relationships, efficiency, continuity and safety [3]. Quality improvement has gained increased attention in recent decades as an approach to increase service effectiveness, particularly in developing countries, and significant efforts have been made to improve the quality of healthcare services [4]. Service quality assessment is the first step to quality improvement [5]. Quality Assessment Framework (QAF) (including quality dimensions and assessment indicators) is one of the standard quality assessment methods [6]. QAFs are developed in accordance with health system requirements, strategies, and objectives. Each country has proposed different dimensions and indicators for quality assessment [7,8,9]. The USA has proposed the dimensions of efficiency, access, health system infrastructure, patient-centeredness, effectiveness, safety, coordination, and timeliness to assess quality of health care [10]. The World Health Organization (WHO) Regional Office for Europe has introduced Performance Assessment Tools for Hospital (PATH) with six dimensions including clinical effectiveness, staff orientation, responsible governance, safety and patient-centered [11]. The variation in QAFs demonstrates the necessity of considering each health system needs, strategies, goals, and service delivery infrastructure when developing these frameworks [12, 13].

To measure the quality and safety of hospitals and create the basis for analyzing the strengths and weaknesses regarding hospital performance, it is crucial to acquire a local and scientific tool based on the hospital conditions [9]. Military hospitals should be assessed based on their unique indicators due to their unique missions and services related to receipting special patients or dealing with biological, chemical, and nuclear disasters [14]. It is necessary to pay special attention to the organizational structure, manpower, type and amount of equipment in developing the performance assessment of military hospitals [15, 16].

To the best of our knowledge, there is currently no local and national framework for assessing the Iran’s military hospitals, while majority of countries in the world use a specific national framework to assess the performance and quality of hospital. This research seeks to develop a comprehensive and scientific framework for measuring multiple dimensions of quality using worldwide experiences. Hospital managers can acquire a comprehensive insight of current performance with the assistance of the data provided by this framework. This study was conducted to develop a Quality and Safety Assessment Framework (Q&SAF) for Iran’s military hospitals through an adjusted framework from WHO.


This is a qualitative study which was conducted in 2023. In order to develop a Q&SAF for Iran’s military hospitals, first, the quality dimensions and indicators as well as the frameworks and models in the scientific literature were identified (Literature review). Then, the expert panels held meetings to adapt the models and frameworks to the local conditions of the country and military hospitals as well as to introduce new indicators in accordance with the potentials and capacities of military hospitals (Expert panel). The results of the expert panel meetings led to the preparation of the initial list of quality and safety assessment dimensions and indicators. After preparing the initial list of indicators, in order to select the final indicators and reach a consensus regarding the final indicators, a qualitative survey was used (Modified Delphi survey). In the next step, the indicators selected based on the expert’s opinion were categorized quality dimensions, and the initial Q&SAF for Iran’s military hospitals was developed (Expert panel). In the last step; content validity index and Modified Kappa were used to finalize and validate the developed framework (Modified Delphi survey). The steps of developing the framework are indicated in Fig. 1.

Step 1: Identifying frameworks, models, dimensions and indicators of quality and safety assessment in the hospital

Fig. 1
figure 1

Irans military hospitals quality and safety assessment framework development flow

The methodology of overview was used in order to identify the models and frameworks for assessing the quality and safety in the hospital, as well as the indicators associated with each framework. Databases of PubMed, Scopus, web of science, and websites related to the WHO using related keywords and their Persian equivalents in Persian databases in the period from 2000 to 2023 were reviewed. The keywords included quality indicator, quality assessment, quality evaluation, quality assurance, performance indicator, standard, quality improvement, Hospital, health center, health facility, inpatient car, model, framework, project, plan. Additionally, a manual search of specialized journals and references of selected articles, organizational reports and other available information sources was done.

The studies that were developed for the hospital environment and also provided a comprehensive framework for assessing quality and safety (considering all aspects of quality and safety and not focusing on a specific dimension or service) were selected for review. Due to the variety of studies, papers written in languages other than Persian and English, studies conducted in settings outside of hospitals, and studies which focused on the quality of specific service or procedure were excluded from the review. Review and screening of studies was done according to Prisma guideline [17] and using Endnote software. In this step, the functional dimensions, the list of indicators and the scope of the identified frameworks were extracted.

Step 2: Preparation of the initial list of quality and safety dimensions and indicators

In this step, the frameworks and models extracted from the literature were reviewed according to the capacities and potentials of military hospitals as well as the condition of Iran’s health system. A qualitative study (expert panel) was used for this objective. Following an initial meeting with experts, the dimensions of the Q&SAF for Iran’s military hospitals were selected. These dimensions were those that were most frequent among the identified frameworks and were most consistent with the conditions of Iranian hospitals. Next, the assessment indicators related to each of the dimension were reviewed. The primary criteria for selecting indicators included: the ability to measure the indicator in the hospital, the importance of the indicator, and the relevance of the indicator to the operational processes of the military hospitals.

Members of the expert panel included individuals with an experience in hospital performance assessment and the quality and safety improvement, as well as other individuals and academic members with related knowledge. These members were selected through the heterogeneous purposeful sampling technique (participants with maximum diversity).

Reviewing dimensions and indicators was done during two face-to-face meetings (Skype platform) for about 1.5 h. During these meetings, in addition to reviewing and selecting the dimensions and indicators extracted from the literature, new indicators suitable to the conditions of military hospitals were also introduced by the experts. In this way, a list of quality and safety assessment indicators was prepared.

Step 3: Final selection of quality and safety indicators

After preparing the initial list of indicators based on the results of the previous steps, a modified Delphi survey [18, 19] was used to reach a consensus about the indicators.

A purposeful sampling technique (according to the type of dimensions and indicators) was used to select participants of survey. The inclusion criteria for the participants included officials and managers of military hospitals and vice chancellor of treatment with at least 5 years of experience, policy makers of the Ministry of Health, and academic members in the fields of health and services management and health economics, health emergencies disaster and health information management.

The selection criteria of the indicators according to the criteria introduced by the WHO [20] included: the importance, feasibility and relevance of the indicator. Each of indicator scored between 1 and 5 based on the three criteria. The indicators were selected using the following parameters: indications with an average of less than 2 were disqualified, those with scores between 2 and 3.5 were returned to the second round of Delphi, and those with a score of 3.5 or more were accepted as the final indicators.

Step 4: Development of an initial Q&SAF for Military Hospitals

The initial framework was developed by the research team and experts based on the findings of the literature review and the qualitative part of the study. To develop the initial framework; the selected final indicators were classified in the selected dimensions in the second step. Also, in this step, for each dimension, related sub-dimensions were defined. The selection process for member of expert panel was similar to the second step.

Step 5: Validation of Q&SAF for military hospitals

The validity of the developed framework was assessed based on the opinions of experts. Accordingly, the initial framework with a detailed description of dimension and indicators sent to 10 experts throughout the Delphi questionnaire. To assess the validity of the framework, 10 items were evaluated. These items included (1) Applicability of the framework (2) Adaptation of the developed framework to the upstream documents (3) Ability to accept the framework by stakeholders (4) Efficiency (5) Flexibility (6) Effectiveness (7) Simplicity (8) Coherence and integration between framework dimensions (9) Comprehensiveness and (10) Overall.

In order to confirm the validity of the framework, modified content validity index and modified Kappa were used. This method was presented by Polit et al. in 2007 [21]. The following formulas were used to calculate Kappa.

$${p_c} = \left[ {\frac{{N!}}{{A!(N - A)!}}} \right]{.5^N} \Rightarrow k* = \frac{{I-CVI - {p_c}}}{{1 - {p_c}}}$$

N = Number of Experts.

A = the number of experts with score of a completely agree and agree.

Experts scored each of the items based on a 4-point Likert scale (completely agree to completely disagree). According to Polit et al.‘s proposal, Kappa lower than 0.40 be considered (necessary), between 0.6 and 0.74 (good) and above0.74 (Excellent).


The Q&SAF for Iran’s military hospitals was developed in five main steps. During the first step, 13 frameworks, 10 dimensions, and 1591 indicators related to each framework were extracted. In the next step, 5 dimensions and 60 indicators were selected based on the findings of the literature review and the recommendations of experts. Based on the results of the Delphi survey, 2 indicators were removed from the 60 indicators and finally 58 indicators were selected. The selected indicators were categorized in the five dimensions (Fig. 2). In the last step, ten experts were asked to assess validity of the framework, and after receiving their feedback, the estimated Kappa index for the framework was 8.9 out of 10.

Fig. 2
figure 2

The results of the development steps of Irans Military Hospitals Quality and Safety Assessment Framework

Step 1: Identifying frameworks, models, dimensions and indicators of quality and safety assessment in the hospitals

After screening the studies and reports extracted from the literature, finally; 13 frameworks along with 10 dimensions and 1591 indicators were identified. The dimensions were compared in order to determine their frequency (Table 1). The identified indicators were initially screened and after removing duplicate and unrelated indicators and merging similar ones, finally 137 indicators were selected.

Table 1 Comparison of quality and safety dimensions in hospitals

Step 2: Preparation of the initial list of quality and safety dimensions and indicators

Experts’ meetings with the participation of 9 experts (3 experts from the army hospital assessment and monitoring department, 6 academic faculty members (2 health management specialist with a focus on service quality assessment, 2 health information management specialist and 2 health emergencies disaster specialist) were held. In addition to the results of the literature review, the list of performance assessment indicators of military hospitals and other related documents about Iranian hospital performance assessment, were also reviewed by an experts’ panel. Based on the results of expert panel meetings, 5 dimensions including clinical effectiveness, safety, efficiency, patient-centeredness and Responsive Management (Command and Control) along with 60 quality and safety assessment indicators (14 indicators by experts and 46 indicators from literature) according to conditions and potential of Iran’s military hospitals were selected. Among the dimensions, the Responsive Management (Command and Control) dimension specifically focuses on the processes and performance of military hospitals.

Step 3: Final selection of quality and safety indicators

The initial list of indicators was reviewed by experts through the modified Delphi survey. The participants in the Delphi survey included 2 experts from the regional office of the WHO, 2 faculty members of the Army University of Medical Sciences, 4 faculty members of medical sciences universities across the country, and 2 hospital managers. Based on the results of the Delphi survey; finally, 58 indicators (out of 60 indicators) scored higher than 3.5 and were selected as final indicators (Table 2).

Step 4: Development of an initial Q&SAF for military hospitals

Expert panel meetings were held to review the final indicators and classify them among the dimensions. Also, in these meetings, sub-dimensions were defined for each dimension. Finally; The Q&SAF for military hospitals was developed with 5 dimensions and 15 sub-dimensions (Table 3). Among the dimensions, the most indicators were related to the efficiency dimension (19 indicators) and the lowest indicators were related to the patient-centered dimension (4 indicators).

Also, among the following sub-dimensions; the most indicators are related to the sub-dimension of financial performance (9 indicators) and the lowest indicators are related to the information security and management (1 indicator), environmental safety management (1 indicator) and combat medicine and military health management (1 indicator).

Validation of Q&SAF for military hospitals

The developed framework was sent to 10 experts (similar to the step 3) in order to validate it. Due to the obtained score above 0.74 in all 12 criteria of the questionnaire, the Delphi survey was completed in the first round and the Q&SAF for Military Hospitals was finalized (Table 4).

Table 2 List of quality and safety assessment indicators in Iran’s military hospitals
Table 3 Quality and safety assessment framework for Iran’s military hospitals
Table 4 Validation scores of the quality and safety assessment framework for Iran’s military hospitals


The Q&SAF for Iran’s military hospitals was developed through the utilization of a mixed-method approach and parallel use of review methods, quantitative, and qualitative methods. This framework has 58 quality and safety assessment indicators categorized under 15 sub-dimensions and 5 main dimensions, including clinical effectiveness, safety, efficiency, patient-centeredness, and Responsive Management (Command and Control).

Utilization of the indicators and dimensions identified from the literature and using the experiences of national and sub-national experts in developing the framework strengthened the study. Developing performance assessment frameworks using the qualitative studies approach and the Delphi technique and expert panel is a common and scientific way that has been used in many studies at different levels of the health system. Bruno et al. (2015) regarding the providing of guideline-based quality indicators for primary care in England, Veena et al. (2005) in the development of coronary artery bypass surgery quality indicators and also, Tabrizi et al. (2013) to develop performance indicators for patient and community engagement and to improve educational management in hospitals, have used the Delphi method and expert panel [36,37,38,39].

According to a review of several assessment frameworks that provided for hospital quality and safety, the primary challenges were related to the incompleteness of some frameworks and inability of some other to coverage all of hospital functional areas [40]. The Q&SAF for Iran’s military hospitals is sufficiently thorough and covers all functions, from clinical to administrative and financial. This important issue has been considered in the WHO-PATH framework and the American Medicare Hospital Comparison Program.

In accordance with most previous frameworks, the majority of the indicators utilized to assess the Iran’s military hospitals quality and safety were at the level of outcome assessment. The experts also believed that the results of the hospital’s performance should be quality-oriented and the framework should assess the results of the activities.

Based on the finding of literature review and comparative review of Q&SAF; The most focus on quality in hospital was the clinical effectiveness dimension, which is assessed in all of current frameworks [41]. This reflects the current trend toward adhering to clinical and evidence-based medical guidelines and highlights the significance of initiatives and methods for assessing the cost effectiveness of services [42]. Accordingly, clinical effectiveness has been considered in the Iran’s military hospitals Q&SAF, and 11 indicators have been assigned to it.

As frontline defenders, health workers are at high risk of infection during the COVID-19 pandemic [43,44,45]. The safety of health workers and patients is a unique advantage in the quality of healthcare and an important priority in healthcare systems [32, 41, 46]. The 13th general work plan of the WHO and the strategic vision of EMRO all prioritize the safety of health workers, and the WHO has considered September 17 as the World Patient Safety Day since 2019 [47, 48]. According to the reviewed frameworks (ACHS and QIP) which pay special attention to the safety dimension, in the Iran’s military hospitals Q&SAF, the patient and health worker safety were emphasized and 14 indicators have been assigned to safety dimension. Hospital efficiency is a lever to improve the development of a health care system. It is important for a hospital to maintain the level of quality in healthcare services while achieving efficient services at the lowest cost [49]. Military hospitals are financed annually through the Global budget [50]. The government’s budget deficit and financial challenges have increased pressure on Iran’s military hospitals to reduced costs [50]. Efficiency must be accurately monitored in order to identify improvements in healthcare productivity [51]. In order to improve the efficiency of military hospitals and in accordance with 9 frameworks extracted from the literature (out of 13 frameworks); efficiency dimension by the largest number of indicators was considered.

The mission of military hospitals is to enhance the health of military personnel by providing health support to a wide range of covered military personnel [50]. Military hospitals are tasked with caring for injured soldiers as well as offering routine medical care to active-duty military members, their families, and retirees [50]. Due to increasing the health literacy of patients and changing the needs of the population; the responsiveness of hospitals has faced fundamental changes. Therefore, the hospital’s response should be patient-centered and should consider the patient’s priorities, needs, values, and clinical decisions in providing health services [52]. Based on this and in accordance with the WHO suggestion regarding the centrality role of patients in the hospital and involving them in providing service processes; one of the important dimensions of the Iran’s military hospitals Q&SAF was assigned to the patient-centered dimension.

In addition to the many similarities that military hospitals have with civilian hospitals in providing health services to the community; in some functional aspects; due to the specific population coverage and specific missions, they have few differences with civilian hospitals [53]. Therefore, in the developed framework, it was necessary to define a specific dimension for military hospitals in accordance with its specific missions. Accordingly, the Responsive Management (Command and Control) dimension with the sub-dimensions of staff management, accidents and disasters management, management and security of data and information, environmental safety management and management of combat medicine and military health were considered. The assessment of these sub-dimensions will be done based on the specific guidelines that were used for military hospitals assessment. Using global experiences to assess the quality of hospitals and combining it with the specific missions of military hospitals can improve the performance of these hospitals similar to civilian hospitals.

The developed assessment framework and associated quality and safety improvement indicators can be tailored for use in civilian hospitals to enhance patient care. The applicability and adaptability of this framework in civilian hospitals can be greatly improved by considering key influencing factors, such as customizing the indicators to fit the local context to ensure their relevance and applicability, integrating them with existing information systems and reporting mechanisms, and conducting pilot tests to gather feedback and make necessary adjustments [54, 55].

The participation of patients and community could increase the comprehensiveness and effectiveness of the framework. One of the study’s limitations is the absence of patient engagement in the framework development process. In order to reduce the impact of this limitation, indicators related to the patient-centered dimension were included.


The Iran’s military hospitals Q&SAF; as a comprehensive tool, provides a suitable opportunity for policy makers and managers to assess the hospitals quality and safety and formulate effective strategies to improve the hospital performance. It is suggested that this framework and its suggested indicators be used for the quantitative and qualitative assessment of Iran’s military hospitals, including the financial resources required to provide health services, human resource management, quality of care, patient and health worker safety, and other functional aspects. Also, this framework can be considered as a reference in assessing and comparing the performance of military hospitals.

Data availability

Data will be made available on request.


  1. Heath I, Rubinstein A, Stange KC, Van Driel ML. Quality in primary health care: a multidimensional approach to complexity. BMJ: Br Med J (Online). 2009;338.

  2. Sahney S, Banwet D, Karunes S. An integrated framework for quality in education: application of quality function deployment, interpretive structural modelling and path analysis. Total Qual Manage Bus Excellence. 2006;17(2):265–85.

    Article  Google Scholar 

  3. Lindsay WM, Evans J. The management and control of quality. South-Western Cengage Learning; 2010.

  4. Baltussen R, Yé Y, Haddad S, Sauerborn RS. Perceived quality of care of primary health care services in Burkina Faso. Health Policy Plann. 2002;17(1):42–8.

    Article  CAS  Google Scholar 

  5. Cheng Lim P, Tang NK. A study of patients’ expectations and satisfaction in Singapore hospitals. Int J Health care Qual Assur. 2000;13(7):290–9.

    Article  Google Scholar 

  6. Kringos DS, Boerma WG, Bourgueil Y, Cartier T, Hasvold T, Hutchinson A, et al. The European primary care monitor: structure, process and outcome indicators. BMC Fam Pract. 2010;11(1):81.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Gardner KL, Sibthorpe B, Longstaff D. National quality and performance system for divisions of General Practice: early reflections on a system under development. Australia New Z Health Policy. 2008;5(1):8.

    Article  Google Scholar 

  8. Shield T, Campbell S, Rogers A, Worrall A, Chew-Graham C, Gask L. Quality indicators for primary care mental health services. Qual Saf Health Care. 2003;12(2):100–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Sullivan-Taylor P, Webster G, Mukhi S, Sanchez M. Development of electronic medical record content standards to collect pan-canadian primary health care indicator data. Stud Health Technol Inf. 2009;143:167–73.

    Google Scholar 

  10. Agency for Healthcare Research. and Quality. National healthcare quality report 2013. 2014.

  11. Groene O, Skau JK, Frølich A. An international review of projects on hospital performance assessment. Int J Qual Health Care. 2008;20(3):162–71.

    Article  PubMed  Google Scholar 

  12. Starfield B, Sevilla F, Aube D, Bergeron P, De Maeseneer J, Hjortdahl P, et al. Primary health care and responsibilities of public health in 6 countries of Europe and North America: a pilot study. Revista Esp De Salud Publica. 2003;78(1):17–26.

    Google Scholar 

  13. Wollschlaeger B. Primary care in the twenty-First Century—An International Perspective. JAMA. 2007;298(6):685–90.

    Article  Google Scholar 

  14. Teymourzadeh E, Babaei M. Hospital accreditation program and its effectiveness in evaluating military hospitals. J Military Med. 2018;20(3):242–3.

    Google Scholar 

  15. Bahadori M, Raadabadi M, Teymourzadeh E, Yaghoubi M. Confirmatory factor analysis of the herzberg job motivation model for workers in the military health organizations of Iran. J Military Med. 2015;17(2):65–71.

    Google Scholar 

  16. Yaghoubi M, Fini SHA, Rahmati-Najarkolaei F. The relationship between customer knowledge management (CKM) on customer relationship management (CRM) tasks in a Military Hospital. J Military Med. 2017;18(4):308–15.

    Google Scholar 

  17. Moher D, Liberati A, Tetzlaff J, Altmann D, Group PRISMA. Preferred reporting items for systematic reviews and metaanalyses: the PRISAM statement. BMJ. 2009;339(21):b2535.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C. Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PLoS ONE. 2011;6(6):e20476.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Azami-Aghdash S, Tabrizi JS, Sadeghi-Bazargani H, Hajebrahimi S, Naghavi-Behzad M. Developing performance indicators for clinical governance in dimensions of risk management and clinical effectiveness. Int J Qual Health Care. 2015;27(2):110–6.

    Article  PubMed  Google Scholar 

  20. Organization WH. Implementation of a quality tool for primary care. Geneva, Switzerland: World Health Organization; 2016.

    Google Scholar 

  21. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health. 2007;30(4):459–67.

    Article  PubMed  Google Scholar 

  22. Groene O, Skau JKH, Frolich A. An international review of projects on hospital performance assessment. Int J Qual Health Care. 2008;20(3):162–71.

    Article  PubMed  Google Scholar 

  23. ACHS 2018 Clinical Indicator Program Information [Internet]. Australian Council on Healthcare Standards. 2018 [cited December 2017].

  24. Busse R, Nimptsch U, Mansky T. Measuring, monitoring, and managing quality in Germany’s hospitals. Health Aff. 2009;28(2):w294–304.

    Article  Google Scholar 

  25. Archer B. Clinical Quality Indicators Development)Indicator Survey Report(NHS the information center for health and social care; 2009 06/02/2009.

  26. (Employers) TNC. In: Employers TNC, editor. 2016/17 General Medical Services (GMS) contract quality and outcomes Framework (QOF). England: The NHS Confederation (Employers); 2016.

    Google Scholar 

  27. Grenier-Sennelier C, Corriol C, Daucourt V, Michel P, Minvielle E. Developing quality indicators in hospitals: the COMPAQH project. Revue D’epidemiologie. Et de Sante Publique. 2005;53:S122–30.

    Google Scholar 

  28. Information CIfH. Canadian Hospital Reporting Project Technical Notes Clinical Indicators. Ottawa, Ontario. 2013 march 2013.

  29. The Joint Commission. USA.

  30. Ontario Hospital Association. Canada.

  31. Simou E, Pliatsika P, Koutsogeorgou E, Roumeliotou A. Developing a national framework of quality indicators for public hospitals. Int J Health Plann Manag. 2014;29(3):e187–206.

    Article  Google Scholar 

  32. Kazandjian VA, Matthes N, Wicker KG. Are performance indicators generic? The international experience of the Quality Indicator Project®. J Eval Clin Pract. 2003;9(2):265–76.

    Article  PubMed  Google Scholar 

  33. The Danish National Indicator Project. Denmark.

  34. Berg M, Meijerink Y, Gras M, Goossensen A, Schellekens W, Haeck J, et al. Feasibility first: developing public performance indicators on patient safety and clinical effectiveness for Dutch hospitals. Health Policy. 2005;75(1):59–73.

    Article  PubMed  Google Scholar 

  35. Flanders D, Pitts S. Quality of health care surveillance systems: review and implementation in the Swiss setting. Swiss Med Wkly. 2002;132(3334):461–9.

    PubMed  Google Scholar 

  36. Guru V, Anderson GM, Fremes SE, O’Connor GT, Grover FL, Tu JV, et al. The identification and development of Canadian coronary artery bypass graft surgery quality indicators. J Thorac Cardiovasc Surg. 2005;130(5):1257. e1-. e11.

    Article  PubMed  Google Scholar 

  37. Rushforth B, Stokes T, Andrews E, Willis TA, McEachan R, Faulkner S, et al. Developing ‘high impact’guideline-based quality indicators for UK primary care: a multi-stage consensus process. BMC Fam Pract. 2015;16(1):156.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Sadegh Tabrizi J, Saadati M, Sadeghi-Bazargani H, Ebadi A, Golzari EJ. Developing indicators to improve educational governance in hospitals. Clin Gov Int J. 2014;19(2):117–25.

    Google Scholar 

  39. Tabrizi JS, Saadati M, Sadeghi-Bazargani H. Development of performance indicators for patient and public involvement in hospital: expert consensus recommendations based on the available evidence. J Clin Res Gov. 2013;2(1):26–30.

    Google Scholar 

  40. Rahim AIA, Ibrahim MI, Musa KI, Chua S-L, Yaacob NM, editors. Patient satisfaction and hospital quality of care evaluation in Malaysia using servqual and facebook. Healthcare: MDPI; 2021.

    Google Scholar 

  41. Copnell B, Hagger V, Wilson S, Evans S, Sprivulis P, Cameron P. Measuring the quality of hospital care: an inventory of indicators. Intern Med J. 2009;39(6):352–60.

    Article  CAS  PubMed  Google Scholar 

  42. Mainz J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care. 2003;15(6):523–30.

    Article  PubMed  Google Scholar 

  43. Lancet T. COVID-19: protecting health-care workers. Lancet (London England). 2020;395(10228):922.

    Article  Google Scholar 

  44. Mhango M, Dzobo M, Chitungo I, Dzinamarira T. COVID-19 risk factors among health workers: a rapid review. Saf Health work. 2020;11(3):262–5.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Narwal S, Jain S. Promoting health worker safety: a priority for patient safety during COVID-19 pandemic and beyond. Indian J Public Health Res Dev. 2020;11:163–71.

    Google Scholar 

  46. Hozesorkhi RM, Vafsi SB, Mohammadimehr M, Kazemi-Galougahi MH, Ebadi A, Afzal M. Development and Psychometric properties of the Caring behaviors of operating Room nurses Questionnaire during the COVID-19 pandemic: a mixed-method study. Iran J Nurs Midwifery Res. 2023;28(4):417–25.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Donaldson LJ, Neelam D. World patient safety day: a call for action on health worker safety. J Patient Saf Risk Manage. 2020;25(5):171–3.

    Article  Google Scholar 

  48. WHO. Thirteenth General Programme of Work, 2019–2023: promote health. Keep the world safe serve the vulnerable. World Health Organization Geneva; 2019.

  49. Chletsos M, Saiti A, Chletsos M, Saiti A. Hospital efficiency and performance. Strategic Manage Econ Health Care. 2019;233:55.

    Google Scholar 

  50. Moradi R, Amiri M. Military hospitals efficiency evaluation: application of malmquist productivity index-data envelopment analysis. Int J Data Envelopment Anal. 2019;7(4):29–40.

    Google Scholar 

  51. Barnum DT, Walton SM, Shields KL, Schumock GT. Measuring hospital efficiency with data envelopment analysis: nonsubstitutable vs. substitutable inputs and outputs. J Med Syst. 2011;35:1393–401.

    Article  PubMed  Google Scholar 

  52. Ree E, Wiig S, Manser T, Storm M. How is patient involvement measured in patient centeredness scales for health professionals? A systematic review of their measurement properties and content. BMC Health Serv Res. 2019;19:1–13.

    Article  Google Scholar 

  53. Bahadori MK, Abolghasemi K, Teymourzadeh E. Performance evaluation and ranking of selective wards in a military hospital using DEA and promethee method. J Military Med. 2017;18(4):325–34.

    Google Scholar 

  54. El Miedany Y, Abu-Zaid M, Elwy M, Mahran S, Elyasaki A, Elgaafary M, et al. AB1145 quality indicators: applying Quality measures to improve services and patient outcomes. A Quality Improvement Initiative. BMJ Publishing Group Ltd; 2023.

  55. Baernholdt M, Dunton N, Grandfield EM, Cramer E. Quality indicators in critical Access hospitals, Small Rural, and Urban hospitals. Online J Rural Nurs Health Care. 2023;23(1):150–72.

    Article  Google Scholar 

Download references


No funding was received for this study.

Author information

Authors and Affiliations



Nader Markazi-Moghaddam: Wrote the paper; Analyzed and interpreted the data, materials.Mojgan Mohammadimehr: Supervised the study methodologyMahdi Nikoomanesh: Interpreted the dataRamin Rezapour: Wrote the paper; collected and analyzed the dataSanaz Zargar Balaye Jame: Supervised the study methodology and drafted the initial manuscript.

Corresponding authors

Correspondence to Ramin Rezapour or Sanaz Zargar Balaye Jame.

Ethics declarations

Consent for publication

Informed consent was obtained from all subjects and/or their legal guardian(s) for publication of identifying information in an online open-access publication.

Competing interests

The authors declare no competing interests.

Ethics approval

This study was part of an approved study in the Research Ethics Committees of AJA University of Medical Sciences (ethical code: IR.AJAUMS.REC.1400.276). The methods were performed in accordance with the relevant guidelines and regulations. “Informed consent” was obtained from all study participants.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Markazi-Moghaddam, N., Mohammadimehr, M., Nikoomanesh, M. et al. Developing a quality and safety assessment framework for Iran’s military hospitals. BMC Health Serv Res 24, 775 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: