Factors Influencing Healthcare Service Quality

Background: The main purpose of this study was to identify factors that influence healthcare quality in the Iranian context. Methods: Exploratory in-depth individual and focus group interviews were conducted with 222 healthcare stakeholders including healthcare providers, managers, policy-makers, and payers to identify factors affecting the quality of healthcare services provided in Iranian healthcare organisations. Results: Quality in healthcare is a production of cooperation between the patient and the healthcare provider in a supportive environment. Personal factors of the provider and the patient, and factors pertaining to the healthcare organisation, healthcare system, and the broader environment affect healthcare service quality. Healthcare quality can be improved by supportive visionary leadership, proper planning, education and training, availability of resources, effective management of resources, employees and processes, and collaboration and cooperation among providers. Conclusion: This article contributes to healthcare theory and practice by developing a conceptual framework that provides policy-makers and managers a practical understanding of factors that affect healthcare service quality.


Introduction
The Iranian healthcare system has been characterised by a strong public sector component. Public healthcare services are complemented by the private sector (i.e. private hospitals and independent medical practitioners' clinics). The healthcare delivery system is structured into three levels. In the first level, Ministry of Health and Medical Education (MoHME) delivers free of charge Primary Healthcare (PHC) services. This level includes rural health houses, rural health centres, urban health posts, and urban health centres. The second level of the system consists of district health centres and district hospitals. The district health centre is responsible for the planning, supervision, and support of the PHC network. The third level of the system consists of the provincial health centres and specialty hospitals (1). All formal workers and their dependents are insured by Social Security Organization (SSO). They receive healthcare services free of charge in SSO facilities. Members of the military forces and their dependents are covered through the Armed Forces Medical Service Organisation (AFMSO). The rest of the population is eligible to enroll in Medical Services Insurance Organization (MSIO), which has four funds covering government employees, rural households, the self-employed, and "others" (e.g. students). The MSIO is compulsory for the government employees and voluntary for the other groups. In addition, charity healthcare institutions focus mainly on providing outpatient services for the poor and healthcare institutions affiliated with the ministries of welfare, oil, and defense provide secondary and tertiary care, mainly to their employees (2).
The health status of Iranians has improved over the last two decades. Approximately 90% of the population has formal health insurance coverage (3). Up to 90% of the rural population and almost the entire urban population have adequate access to PHC services. As a result, child and maternal mortality rates have fallen significantly, and life expectancy at birth has risen remarkably. Life expectancy at birth increased to 73 years of age. With respect to health indicators, 95% of the population has access to safe drinking water. Additionally, 99% of children reaching their first birthday are fully immunised. The crude birth and death rates are 16.8 and 5.3 per 1,000 respectively. The total fertility rate is 1.6 per woman. The maternal mortality ratio is 21 per 10,000 births (4). Despite these achievements, Iran's healthcare system faces a number of serious challenges, particularly concerning health outcomes, i.e. quality and efficiency (5)(6)(7)(8). A full understanding of the concept of quality and the variables influencing healthcare services quality is needed to improve healthcare services quality. positive company image (9,10). As a result, productivity and profitability improve (11). Therefore, it is very important to define, measure and improve quality of healthcare services. Quality, because of its subjective nature and intangible characteristics, is difficult to define. Definitions vary depending on whose perspective is taken and within which context it is considered. No single universally accepted definition exists. Quality, therefore, has been defined as 'value' (12); 'excellence' (13); 'conformance to specifications' (14); 'conformance to requirements' (15); 'fitness for use' (16); 'meeting and/or exceeding customers' expectations' (17), and 'consistently delighting the customer by providing products and services according to the latest functional specifications which meet and exceed the customer's explicit and implicit needs and satisfy producer/provider' (18). Healthcare service quality is even more difficult to define and measure than in other sectors. Distinct healthcare industry characteristics such as intangibility, heterogeneity and simultaneity make it difficult to define and measure quality. Healthcare service is an intangible product and cannot physically be touched, felt, viewed, counted, or measured like manufactured goods. Producing tangible goods allows quantitative measures of quality, since they can be sampled and tested for quality throughout the production process and in later use. However, healthcare service quality depends on service process and customer and service provider interactions (19,20). Some healthcare quality attributes such as timeliness, consistency, and accuracy are hard to measure beyond a subjective assessment by the customer. It is often difficult to reproduce consistent healthcare services. Healthcare services can differ between producers, customers, places, and daily. This 'heterogeneity' can occur because different professionals (e.g. physicians, nurses, etc.) deliver the service to patients with varying needs. Quality standards are more difficult to establish in service operations. Healthcare professionals provide services differently because factors vary, such as experience, individual abilities, and personalities (21). Healthcare services are simultaneously produced and consumed and cannot be stored for later consumption. This makes quality control difficult because the customer cannot judge 'quality' prior to purchase and consumption (22). Unlike manufactured goods, it is less likely to have a final quality check. Therefore, healthcare outcomes cannot be guaranteed. Quality healthcare is a subjective, complex, and multidimensional concept. Donabedian defined healthcare quality as 'the application of medical science and technology in a manner that maximises its benefit to health without correspondingly increasing the risk' (23). He distinguishes three components of quality: 1) technical quality, 2) interpersonal quality, and 3) amenities. Technical quality relates to the effectiveness of care in producing achievable health gain. Interpersonal quality refers to the extent of accommodation of patient needs and preferences. Amenities include features such as comfort of physical surroundings and attributes of the organisation of service provision (24). Øvretveit defines quality care as the 'Provision of care that exceeds patient expectations and achieves the highest possible clinical outcomes with the resources available' (25). He developed a system for improving the quality of healthcare based on three dimensions of quality: professional, client, and management quality. Professional quality is based on professionals' views of whether professionally assessed consumer needs have been met using correct techniques and procedures. Client quality is whether or not direct beneficiaries feel they get what they want from the services. Management quality is ensuring that services are delivered in a resource-efficient way. According to Schuster et al. good healthcare quality means "providing patients with appropriate services in a technically competent manner, with good communication, shared decision making and cultural sensitivity" (26). For Lohr, quality is "the degree to which healthcare services for individuals and population increases the likelihood of desired healthcare outcomes and is consistent with the current professional knowledge" (27). Mosadeghrad defined quality healthcare as "consistently delighting the patient by providing efficacious, effective and efficient healthcare services according to the latest clinical guidelines and standards, which meet the patients needs and satisfies providers" (18). He identified 182 attributes of quality healthcare and grouped them into five categories: environment, empathy, efficiency, effectiveness and efficacy. Quality healthcare includes characteristics such as availability, accessibility, affordability, acceptability, appropriateness, competency, timeliness, privacy, confidentiality, attentiveness, caring, responsiveness, accountability, accuracy, reliability, comprehensiveness, continuity, equity, amenities, and facilities (20). Various healthcare stakeholders' perspectives, desires and priorities must be considered in any effort to define, measure, and improve quality of healthcare. While several empirical studies have been carried out to assess the quality of healthcare organizations (28,29), few researches have been conducted to identify factors that affect quality of healthcare services. Very limited studies have addressed this issue in Iranian healthcare organizations (30). Most studies were limited to one or at the most two healthcare stakeholder perspectives. This study, therefore, aims to fill this research gap by empirically exploring healthcare providers' , managers' , payers' , and policymakers' perspectives on factors affecting healthcare services quality in Iranian healthcare organizations.

Purpose
The main purpose of this study was to identify factors that influence healthcare services quality in the Iranian context.

Method
Owing to healthcare complexity and multi-dimensionality, research exploring healthcare quality is methodologically difficult. There are many participants involved in healthcare delivery, each having their own interests and concerns. Hence, quality assessment cannot be carried out reliably by asking one stakeholder alone. Pluralistic evaluation (31) can overcome professionally dominated healthcare evaluation traditions by identifying and representing stakeholder group views, including the marginalised. The pluralistic approach does not rely on consensus, but evaluates multiple perspectives. Hence, each stakeholder group has their views and concerns represented in the evaluation (32). As a result, objective findings can be obtained. This study represents an exploratory effort in understanding factors affecting healthcare services quality in the Iranian context. A qualitative approach is appropriate to answer the research question. A qualitative research typically produces detailed and in-depth information about a much smaller number of people and cases. This increases understanding of the cases and situations studied and enhances the validity of the data obtained (33). It is often inductive, with propositions emerging at the end of the study rather than being hypothesis driven. However, the qualitative research is labour-intensive, costly, time consuming, and demands the highest level of expertise to undertake the research and interpret the findings (34). It also suffers the limitations in generalising the results to a larger population. Interviews provide a useful means to access in-depth information on the attitudes and behaviors of subjects towards different phenomena (35). Interviews encourage the participant to tell 'the story' in their own words. This is most beneficial for this research. It enables the researcher to uncover factors that can affect healthcare services quality. However, interviews are not problem-free. They can be time consuming, costly, and prone to subjectivity and bias on the part of the interviewer (36). Stakeholders' perceptions about what factors affect healthcare service quality often reflect their individual experience rather than a general view. Interaction between participants in focus groups can help overcome this. A focus group is a group interview technique designed to promote interaction between members of a group to stimulate deeper discussion, reduce social and cultural constraints on participation, and reveal new facets of the discussion topic (37). Focus group discussion generates qualitative data from a group of people much more quickly and at less cost than would be the case if each individual were interviewed separately. Focus groups allow the researcher to interact directly with respondents. This provides opportunities for the clarification of responses, for follow up questions and for probing of responses (38). Focus group discussion helps to explore factors influencing healthcare services quality and explain the reasons for their occurrence. Therefore, in-depth individual and focus group interviews were conducted in this research using a semi-structured format with key healthcare stakeholders in Isfahan, Iran. These included healthcare providers (doctors, nurses, and paramedics), managers, policy-makers, and payers.

Settings and participants
The study was carried out at eight hospitals, four MoHME hospitals (three teaching and one non-teaching), two SSO affiliated and two private hospitals to represent the three dominant hospital care systems in Iran. In-depth interviews were used for gathering doctors, managers, policy-makers, and payer's perspectives. This study also relied on focus groups with providers (except doctors) to explore their opinions on factors affecting healthcare quality. In each hospital two focus group discussions were conducted with nursing staff and paramedics (See Table 1).

Data collection
A semi-structured interview schedule was designed for the study. The interview schedule consisted of open-ended questions to allow respondents to answer from a variety of dimensions. Participants were asked to articulate factors that facilitate the delivery of quality healthcare services. The interviews were recorded digitally with the participants' permission to facilitate analysis. Notes were taken for those participants who were reluctant about voice recording.

Data collection and analysis
The digital files were transcribed by the author himself. Content analysis was used to detect and code factors affecting quality of healthcare services, organise them into logical and meaningful categories, make connections between and among categories, and explain the link between categories. NVivo version 7 (QSR International, Australia) was used for qualitative data analysis and retrieval.

Evaluating the quality of research
The researcher has not allowed personal values to influence the conduct of the research and findings derived from it. Member checks (respondent validation) were done in face-toface discussions with a subgroup of participants in order to verify and validate the findings. The researcher also utilised peer debriefing with five quality management experts. Peer reviewers debriefed with the researcher by presenting a summary of the gathered data, categories and themes that emerged, and the researcher's interpretations of the data. The peer debriefers provided the researcher an opportunity to clarify his interpretations about the nature of quality healthcare and to examine his biases.

Results
The views of participants on factors influencing the quality of healthcare were grouped into three main categories and 10 themes (Table 2). Factors related to both the provider and receiver of the healthcare service and the environment affect the quality of provided services.

Patient socio-demographic variables
Socio-demographic factors influence the interaction between a provider and the patient and consequently the quality of services. For instance, a physician stated "I worked in a health centre in a village. . Some patients ask their doctors to prescribe medicines. They believe that they will not be healed unless they take medicines. Patient persistence to get a specific medicine influences physicians to do so to satisfy the patient: "For a simple cold for which the patient needs supportive care, s/he insists to get penicillin. If I do not prescribe it, s/he will go to see another physician" (MD20). Some doctors believe that it is even useless to explain the treatment process to a patient demanding medicine: "Explaining the disease and its treatment process to a patient demanding a medicine for about half an hour will not satisfy him/her more than if you just prescribe antibiotics, which takes about 2 minutes of your time" (MD20). Lack of a robust referral system and a low medical tariff are the main reasons for a doctor's tendency to meet patient (irrational) requests. Patients have easy access to affordable medical services: "Medical services are easily available. You can see a medical specialist easily whenever you want" (MD23). Therefore, patients can easily switch from one provider to another one. On the other hand, the high cost of running a medical clinic forces physicians to see more patients. "A physician has to pay for the rent, bills, tax, and secretary wages. The income from the first 18 patients goes to the expenses [breakeven-point]. Therefore, s/he has to see more patients". (PM2) "When medical tariff is low, a physician has to compensate it with quantity [seeing more patients]" (MD18). There is a need for an isolation room which is not here" (PRG1).

Provider socio-demographic variables
The character and personality of healthcare provider affect the quality of healthcare services. "The physician's appearance and relations with a patient affects the quality of service" (MD52). Medical doctors develop good rapport with their patients using some personality characteristics such As respect, helpfulness, reliability, intelligence, and confidence: "Physician personality is important. Some physicians built a good relationship with patients. It helps patient to trust the doctor and cooperate in the treatment process" (MD46). However, there should be a link between physicians' attitude and communication with patients and their received income.
In a public hospital that the demand for medical services is very high, physicians are not motivated to improve their communication skills: "Some doctors particularly in public hospitals realized that their communication skills are not linked to their income level. Thus, they may not change their attitude and behavior" (MD7). Providers' personal and family problems also influence their behaviour and the quality of services provided to patients. Some participants raised these kinds of issues by asserting that: "Being happy with the personal life affects the work of a physician" (MD37). "Family problems decrease the quality of services" (PRG5 Medical universities have a critical role in providing education and professional development opportunities for the healthcare workforce. Unfortunately, most healthcare professionals are not satisfied with the quality of education in the universities "There are some shortcomings in the medical education" (MD6). "The graduates are not practically competent" (MD3). "In the university we learn more theory. We have no practical experience" (MD22). Healthcare professionals demanded more relevant and practical education and training. "We are taught about some rare or uncommon diseases that we will forget later. For the common diseases there is just theoretical education" (MD37). "The way to communicate with patients is not taught" (MD3). "There is no formal education in medicine prescribing. I have to learn that by myself. " (MD7) and "The theoretical perspective of nursing education is good. However, graduates are not practically competent" (PRG15). Therefore, hospitals provide additional education and training to meet employees' educational needs. However, the effectiveness of the education provided is questionable: "The hospital provides some educational programmes. However we are so tired that we end up sleeping in the class". (MD15) and "Working too much reduces the motivation for study. I have to work 216 hours a month" (MD46).

Provider motivation and satisfaction
Providers' job satisfaction is very important in delivering highquality services to patients. Healthcare providers identified nine organisational factors they believed influence their motivation and consequently job satisfaction. These were pay, working environment, managerial leadership, organisational policies, co-workers, recognition, job security, job identity, and chances for promotion.

Healthcare system
There is no referral system from the primary healthcare level to the secondary and tertiary levels in Iranian healthcare system. Therefore, there is a tendency, in patient choice from a GP to a medical consultant: "Lack of a referral system resulted in a shift of patient choice from general practice to sub-speciality practice. Most patients prefer to be seen by a medical specialist. Nowadays, a GP has fewer patients than a medical consultant" (MD3). Low medical tariff makes it easier for patients to see a medical specialist: "The disparity between the service fee of a GP and a [medical] consultant is not too much. Therefore, patients prefer to be seen by a medical specialist" (MD19). Medical insurance companies make it even more affordable for patients to see a medical specialist. Organisations' differences in financial resources affect their quality of service" (MA6).

Leadership and management
Effective management was mentioned as an important enabler of quality from the perspective of providers, managers, policymakers and payers. "Everything in the hospital is affected by the management. If people have good ideas for quality improvement, but there is no good management, those ideas would be useless". (PRG8). Some participants complained about the lack of professional managers in healthcare organisations; "Management is not professional here [hospital]. They do not have experience and knowledge in management. They just try to resolve problems in short terms" (PRG2). There are no objective criteria for selecting and appointing managers in healthcare organisations: "There are no criteria for recruiting or dismissing managers" (MA5). "Managers' selection and appointment is not based on objective criteria. It is based on personal connections" (PM4). The analysis of qualitative data indicated that the lack of management stability was considered a major obstacle facing the managers trying to extend their knowledge and experience. "There is no job security for managers. There is a need for collaboration between the hospital and insurance company to solve these kinds of problems" (PA3).

Discussion
Quality in healthcare is a production of cooperation between the patient and the healthcare provider in a supportive environment. Healthcare service quality depends on personal factors of the healthcare service provider and the patient and factors pertaining to the healthcare organisation and broader environment. Differences in internal and external factors such as availability of resources and collaboration and cooperation among providers affect the quality of care and patient outcomes. A number of theoretical relationships can be inductively inferred from the preceding analysis. These relationships are depicted in Figure 1. This model illustrates a variety of individual, organisational, and environmental factors that influence a caregiver's job satisfaction and consequently commitment in providing highquality services. Individual factors include age, personality, education, abilities, and experience. Organisational factors include management style, working conditions, and relationships with co-workers. Environmental factors consist of economic and social influences. Furthermore, customer related factors such as socio-demographic variables, attitude, and cooperation influence the quality of care provided. The provider's subjective attributes, including the priority they give to care, would have a moderating influence on the delivery of care. This study showed that hospital employees burdened with heavy workloads, poor compensation packages, low quality of work life, and poor leadership. All of these factors have impeded the delivery of quality patient services particularly in the public health sector. These findings are consistent with previous studies in Iran (39)(40)(41)(42)(43)(44). In this study, clear relationships between employee satisfaction, quality of care, and patient satisfaction was found. These findings support earlier researches (45,46). Good human resource management drives employee satisfaction and loyalty (47,48). Effective human resource management can also have a significant effect on customer satisfaction. Satisfied and committed employees deliver better care, which results in better outcomes and higher patient satisfaction (49)(50)(51).
The findings suggest that healthcare quality can be improved by supportive leadership, proper planning, education and training, and effective management of resources, employees, and processes. If policy-makers and managers intend to improve healthcare services quality, they should apply techniques and tools to operationalise these quality management constructs. However, there are some obstacles that prevent the successful introduction of quality management models. Some of these organisational morbidities are explained below. Centralization, bureaucracy, and severe dependency on government with a strong hierarchical structure are important barriers to effective quality management in the Iranian healthcare system. Almost all decisions regarding the structures, general goals, policies, and even resource allocation are made at the central level by the MoHME. Managers in public healthcare organisations do not have autonomy to make and implement strategic decisions. An effective quality management system requires more autonomy for operational managers in the decision-making processes. The MoHME determines health policies, delivers, and evaluates healthcare services. While the ministry of health participates in developing standards and policies, an accreditation council comprising representatives from government regulatory agencies, professional organisations, practitioners, and the public should be created to govern the accreditation programme. Quality management principles should be incorporated into healthcare evaluation and accreditation standards. Several ministries, organisations, and institutions are involved in the provision of healthcare services in Iran, which make the healthcare system less efficient. They pay differently to their employees. It resulted in a feeling of inequity, de-motivation and dissatisfaction among employees. The quality and tariff of services are also different in these healthcare organisations, leading to patient dissatisfaction. Nationalisation of healthcare services decreases the feeling of inequity among healthcare providers and clients. Many Iranians cannot afford the costs of healthcare services on their own. There are many public and private medical insurance programmes in Iran. A national (Universal) programme of comprehensive health insurance helps to decrease the inequity in access to services for patients. It is very difficult to sustain the benefits of a quality management system in Iranian healthcare organisations while they are suffering from these organisational diseases.
Managers and policy-makers must invest in the following five capitals (see Figure 2) to overcome the above-mentioned obstacles and facilitate the implementation of quality management (52). Physical capital refers to any non-human asset used in the production of products and services. Quality is not free. High-quality resources are needed to provide high-quality services. Healthcare organisations should provide their staff with the resources and support they need to deliver highquality services (52). In 2010, Iran spent 5.3% of its Gross Domestic Product (GDP) or 302 US dollars per capita on health versus 3,495 US dollars in the UK, and 8,233 US dollars in the USA (4). A much higher percentage of the national GDP should be allocated to the healthcare system to improve healthcare services quality. The organisational structure in Iranian healthcare organisations should be changed to support quality improvement activities. The new quality structure should be supported by adequate staff, facilities, and resources. A clinical governance system should be established for defining clinical standards and monitoring performance against standards (53). Using a quality-oriented information system helps in studying the processes and identifying and then prioritising quality problems. Human capital refers to the skills, experience, and knowledge gained by an employee to perform the job well. The quantity and quality of healthcare providers affect the quality of services. High-quality providers are critical to producing high-quality outcomes. Healthcare managers should have distinctive approaches for the attraction and the retention of qualified Figure 2. Star Capital employees that are able to deliver the highest-quality care. The current recruitment policies and practices in Iran should be reviewed to support managers in identifying and recruiting the most appropriate personnel to provide a quality service. This might involve operational managers and supervisors in staff selection and the use of performance-related criteria and psychometric tests for selecting staff. Continuing professional development is the most important investments in human capital. Peer review and professional revalidation also help to develop employees' capabilities. Employees' training takes time, expertise, and money. Therefore, universities should play a more active role in the effective training of human resources for healthcare organisations. Medical universities should offer quality-related courses in their academic programmes for medical and paramedical students. In addition, a continuous organisational learning team should be organised within the healthcare organisations to meet further employees' educational needs. This study emphasised the need to properly reward and recognise employees. Employees perform better when they feel recognised and appreciated (54). Employees' payments should be linked directly to the quality of their services, their performance and customer satisfaction. The fee-for-service payment method can discourage cooperation and collaboration across the delivery system in providing of effective and efficient healthcare services as it encourages providers to provide more services for the patients to maximise their own economic interests. Social capital is about one's responsibility and accountability to society and human beings. It consists of the norms, obligations and trust embedded in social relations, which enable participants to act together more effectively and to pursue shared objectives (55). Accountability, coupled with transparency of information, help improve social capital. Professionals must be accountable to those they serve for the quality of care delivered. Delivering high-quality healthcare services is a corporate social responsibility of an organisation. Although improving productivity has been emphasised in the Iranian national development plan, there is no criteria for measuring achievement. Therefore, managers are not responsible enough towards increasing the productivity of healthcare organisations through the improvement of the quality of services. Regulatory bodies can support accountability through their core functions. This includes maintaining a register of professionals, setting standards for education and training, requiring continuing professional development, and providing guidance on standards and ethics. Education has a very powerful and positive effect on social capital. Successful quality management implementation requires a significant change in mindsets, attitudes, and beliefs of individuals with regard to quality. Teamwork and collaboration should be fostered. Good communication, cooperation, and collaboration among healthcare providers support providing effective and efficient healthcare services, and promote shared responsibility for patient care. In Iranian healthcare, decisionmaking is centralized, the workforce is not empowered and there is a lack of trust amongst managers and employees. Mistakes bring blame seeking and dismissal and teamwork is thought to be unnecessary. Changing established behaviour and practices of an organisation is not easy (56). Education

Cultural capital
Human capital

Social capital
Leadership capital of the next generation in schools and universities on participation and teamwork concepts and skills, continuous improvement, and customer focus by the national TV or radio, ISIRI, etc. could be helpful. The increasing complexity of healthcare services, treatment options and care pathways requires a more knowledgeable and participative customer to achieve the most satisfactory outcomes. More active informed customer involvement reduces inappropriate use of healthcare services and errors and improves the quality of services through constructive criticism. However, customers lack knowledge about their rights in Iranian healthcare organisations (57,58). The media and education system must play an active role in increasing public knowledge about healthcare services. Customer advocate institutions like the National Council for Quality Healthcare and the patients association should be established at the national level to make sure healthcare organisations are accountable enough in providing high-quality services. Healthcare organisations should also establish a patient relations department to provide patient advice and liaison service. The success or failure of quality management is first of all in the hands of leaders (59). Leadership capital is the leader's ability to direct an organisation forward in a positive direction. It is important that managers develop their leadership skills and demonstrate their commitment to quality by establishing a shared vision and setting a clear direction for the organisation. Managers should transform their organisation's value system and ultimately the organisational culture, policies, and structure in order to meet the needs of their employees and customers. Iranian healthcare managers have been blamed for being short term oriented, conservative, non-participative, and non-scientific (60,61). Medical doctors without management expertise have occupied most of the managerial key positions in Iranian healthcare organisations. They rely more on practical experience as a vehicle for learning about management (60). Decision-making tends to be based on intuition rather than use of reliable information. As healthcare organisations are growing in number and complexity, there is an ever-growing need for professional management and governance that is accountable for continuously improving corporate (clinical, operational, and financial) performance. The introduction of professional management into the healthcare system increases managerial control of services and promote organisational productivity. Iranian healthcare organisations can be managed better by having well-trained managers supporting and leading the teams that manage the processes to deliver the best possible care for patients. Findings of this study confirm that managerial knowledge and skills are key success factors for the effective management of an organisation. Leaders' personality traits are also crucial to leadership effectiveness in organisations. These include personal motivation, enthusiasm, intelligence, conscientiousness, self-confidence, skill in dealing with people, and capacity to motivate others (62,63). A programme should be developed to select, train, and develop professional managers for healthcare organisations. Training opportunities must be offered to help managers develop their management and leadership skills. Quality management methods should be also integrated into the management education curriculum. The MoHME should invest considerably in leadership development programmes for clinicians and managers.

Limitations and implications for further research
Respondents were healthcare organisation stakeholders in Iran and the results of the study cannot be generalised to other countries or healthcare systems. Hence, future studies may want to explore and identify factors that affect quality of healthcare services in other countries. The model presented in this paper needs to be confirmed empirically.

Conclusion
The pluralistic evaluation in this study revealed a comprehensive picture of factors affecting quality and the reasons for their occurrence in a way that would not have been possible had a singular evaluation approach been used. As the demand for healthcare services is increasing, most healthcare organisations find themselves overwhelmed with large volumes of patients. With such robust market, many providers cannot justify the cost of trying to improve the system. The majority of healthcare providers involved in this study stressed that quality of healthcare services is severely limited by lack of resources. In such a context, patient concerns could not be taken into account. In addition, public healthcare organisations deal with frequent management turnover. Important changes are required in a number of aspects of healthcare system in Iran if healthcare organisations are to provide high-quality services.

Ethical issues
Ethical codes in this study involved (i) respect for human dignity, (ii) respect for privacy and confidentiality, and (iii) respect for autonomy.