Evidence-based performance measurement (a case study of Tehran medical sciences teaching hospitals)

ABSTRACT

Hospital evidence is considered a new and fundamental component in the field of health and treatment services, and among all the services provided in medical environments, it is of particular importance because, systematic and comprehensive research, increases knowledge and develops organizational decisions to establish, implement and develop new policies in the field of health. This research has been done to design an evidence-based performance evaluation model for teaching hospitals of medical sciences in Tehran. The present research is descriptive-interpretive with a mixed approach. The studied population includes 6208 employees of medical sciences teaching hospitals in Tehran and a sample of 362 people were studied. In the current research, semi-structured interviews were used to collect data in the qualitative part and a questionnaire in the quantitative part. The analysis of the findings was done in the qualitative part with MaxQDA software and in the quantitative part with EXCEL, SPSS, and LISREL software. In total, 13 main variables were identified as effective factors in the evidence-based performance system of Tehran medical science teaching hospitals, and it was found that there is a significant relationship between each of these factors.

KEYWORDS:

• Evidence-based practice
• teaching hospitals
• medical sciences

1. Introduction

The hospital is a very complex, multi-specialist, and bureaucratic social organization that plays an important role in providing, maintaining, and promoting the health of the community, and responding to the clinical and non-clinical needs of the people of the community and their health is considered one of the main goals of the hospital [1].

Hospitals account for half of the budget of the health system, and the policymakers and managers of the health system, due to the high cost of hospitals, want optimal performance and the provision of quality, safe, effective, and efficient services [2]. Therefore, in the past three decades, several reforms have been implemented in different countries of the world to improve the quality, responsiveness, effectiveness, and efficiency of hospitals and increase patient satisfaction, which governments periodically evaluate with licensing, evaluation, and accreditation methods [3].

The performance of hospitals and by using different methods of self-evaluation and by identifying opportunities for improvement, they apply the necessary corrective measures to improve the performance of hospitals, and one of the most important principles and tools for measuring this is hospital evidence and evaluations based on this It is evidence [4]. Hospital evidence is considered a new and fundamental component in the field of healthcare services and among all the services provided in medical environments such as hospitals, evidence is of particular importance because hospital evidence with systematic and comprehensive research [5].

Increases the knowledge and development of organizational decisions to establish, implement and develop new policies in the field of health and can reduce to some extent the challenges and problems of health, treatment, education, and medicine in the country, for this reason, providing quality and suitable Tables 1 to 4 services as A priority has been raised in the healthcare service system [6].

Table 1. Demographic characteristics of hospital staff.

Demographic characteristics		A boundness	Percentage
gender	Male	307	%85
	female	55	%15
Age	Less than 35 years	84	%23
	35 to 45 years	166	%46
	45 years and more	112	%31
Education	Masters	186	%51
	MA	135	%37
	P.H. D	41	%11
Work Experience	Less than 10 years	77	%21
	10 to 15 years	105	%29
	15 to 20 years	114	%31
	More than 20 years	66	%18
Total	362		%100

Table 2. Test for normality of data distribution.

Variable	Significance (Kolmogorov-Smirnov Test)	Significance (Shapiro-Wilk Test)	Qualification
Clinical Effectiveness	0.105	0.972	Normal
Evidence-based performance evaluation	0.136	0.951	Normal
Staff requirements	0.100	0.975	Normal
Strategic planning	0.122	0.965	Normal
Organization mission statement	0.115	0.960	Normal
Patient-centered	0.106	0.962	Normal
Empowerment of human resources	0112	0.972	Normal
Getting satisfaction	0.175	0.949	Normal
Accountability governance	0.135	0.949	Normal
Support services	0.174	0.926	Normal
Quality and safety of services	0.118	0.958	Normal
Hospital management	0.135	0.969	Normal
Responsibility	0.099	0.978	Normal
Central -employee	0.080	0.969

Table 3. Summary of the results of the structural part of the model (relationships of model variables).

Independent variable	Dependent Variable	Operational burden	T-Test	Total
Clinical effectiveness	Evidence-based performance evaluation	0.303	3.344	Validity
Staff requirements	Evidence-based performance evaluation	0.317	3.626	Validity
Strategic planning	Evidence-based performance evaluation	0.279	2.738	Validity
Organization mission statement	Evidence-based performance evaluation	0.391	4.543	Validity
Patient-centered	Evidence-based performance evaluation	0.341	3.544	Validity
Empowerment of human resources	Evidence-based performance evaluation	0.289	2.997	Validity
Getting satisfaction	Evidence-based performance evaluation	0.374	3.990	Validity
Accountability governance	Evidence-based performance evaluation	0.303	3.049	Validity
Support services	Evidence-based performance evaluation	0.707	9.908	Validity
Quality and safety of services	Evidence-based performance evaluation	0.356	3.649	Validity
Hospital management	Evidence-based performance evaluation	0.459	6.589	Validity
Responsibility	Evidence-based performance evaluation	0.317	3.586	Validity
Central employee	Evidence-based performance evaluation	0.515	7.404	Validity

Table 4. Summary of the evaluation results of the model structure.

Main structures	Detection coefficient	Q2	F2	GOF
Clinical effectiveness	–	0.304	0.194	0/715
Evidence-based performance evaluation	0/902	0.465	0.203	–
Staff requirements	–	0.698	0.309	–
Strategic planning	–	0.555	0.166	–
Organization mission statement	–	0.623	0.222	–
Patient-centered	–	0.519	0.115	–
Empowerment of human resources	–	0.600	0.208	–
Getting satisfaction	–	0.587	0.211	–
Accountability governance	–	0.520	0.127	–
Support services	–	0.501	0.124	–
Quality and safety of services	–	0.572	0.198	–
Hospital management	–	0.541	0.152	–
Responsibility	–	0.545	0.147	–
Central employee	–	0.495	0.123	–

In this regard, managers and medical staff of hospitals are expected to provide services and care with the highest quantitative and qualitative standards based on practical findings, and always by reviewing and revising care methods, they have the necessary ability to make decisions [7]and gain clinical skills in providing quality services [8].

Evidence-based practice has been established as an indicator of the quality of health care and treatment, in which modern, reliable, and quality-assured healthcare services are emphasized, in this regard, employees must be connected with up-to-date evidence to make clinical decisions [9].

Become familiar with and instead of outdated primary education, by relying too much on individual experiences, strengthen this evidence and leave behind a proper performance in the field of health and treatment services, and through the integration of this evidence to solve the challenges and the problems of all hospitals, especially educational hospitals, should take firm steps [10].

During all these times, the officials and managers of the hospital, as well as the health system, have faced many challenges and problems in the field of developing hospital services and measuring and evaluating its performance, and they have all come to a consensus on how to more effectively bridge the gaps [11].

Between what is known and what needs to be done in practice to improve the conditions of the health system, the only way they have achieved it is to evaluate the performance of hospitals practically, and the only tool for practical measurement of the performance of hospitals is to rely on evidence.

Even though for the past 50 years, the main focus of health system researchers has been on the production of empirical knowledge to improve clinical practice, since the last decade, the focus and emphasis have been on using research findings in practice with the aim of professional development of the health system and hospital [12,13] to be based on evidence has continued [14].

Considering that in the scientific map of the country, to improve the quality of service and increase satisfaction with community satisfaction and encourage the provision of health services provided to the use of clinical guidelines, we focus on the contribution of hospitals to health services following developed standards, and with emphasis on clinical governance, with the participation of hospitals [15].

All of the above indicates the need for hospitals to establish clinical governance and evaluate evidence-based performance with the use of clinical guidelines, to facilitate operational conditions of evaluation of evidence-based performance evaluation [16].

To achieve this, we need to use regulatory patterns and patterns to adapt hospitals with knowledge of the world’s day and prepare them for new and systematic change [17].

Therefore, the design of an evidence-based performance evaluation model in the country’s hospitals, especially teaching hospitals, is necessary and essential because the evidence-based performance evaluation is in a supportive space with rational decision-making and its main focus is on decisions [18].

It is clinical and constructive in hospital management, and with its help, it can partially overcome the problems and challenges in the health system and discussions with hospitals [19,20].

The implementation of scientific and systematic research should answer the following main question: What is the evidence-based performance evaluation model of medical sciences teaching hospitals in Tehran?

1.1. Methodology

The current research aims to develop applied knowledge in a specific field of knowledge and it was done to use the results of the findings to solve specific problems within the organization, so the current research is applied research. It is purposeful and descriptive-interpretive research with a mixed approach that is used to collect data through field research.

Statistical population, sample size, and sampling method the statistical population of this research includes all members of the medical science teaching hospitals of Tehran city, their number is 6208 people, of which 362 people were selected randomly and according to the conditions. The criteria for entering the research were that the sample could understand the topic of the research and was willing to cooperate and participate in the research.

In the current research, the main tool for data collection in the qualitative part was semi-structured. Based on the components obtained from the qualitative part, a researcher-made questionnaire was prepared for the quantitative part and it was calculated based on the five-choice Likert scale. Cronbach’s alpha test was used to measure the validity of the questionnaire. The results showed that Cronbach’s alpha of the questionnaire was above 0.7, which indicates the reliability of the instrument used.

Ferrell and Choker’s method was used for sampling extension. These two methods determined the deviation of a quality characteristic from its target value based on the Taguchi loss function.

1.2. The studied community

Teaching hospitals refer to hospitals that are managed under the supervision of universities of medical sciences and, in addition to providing medical services to patients, they train medical and nursing students and other specialties related to medicine. Doctors who practice medicine in teaching hospitals are members of the academic faculty of the university, the head of the hospital, and all departments of the teaching hospitals are determined by the University of Medical Sciences under which the hospital is managed. The total number of them is 6208 people. The study population was all doctors, medical staff and office workers.

1.3. Ethical approval

The study complied with Tehran University of Medical Science (TUMS) Ethics Committee Guidelines for research with humans and has been approved by the Helwan University Ethics Committee (Serial number: 48–2020), organized, and operated according to the declaration of Helsinki 1975. Participants gave their consent electronically before starting to respond to the survey questions by answering a question at the beginning of the survey taking participants’ consent to participate in the study by “Yes.” Participants acknowledged that they could not be identified via the paper, and that they had been fully anonymized in the research.

1.4. Statistical population, sample size, and sampling method

The statistical population of this research includes all the members of teaching hospitals of medical sciences in Tehran, whose number is 6208 people, of which 362 people were selected by simple random and according to the Cochran formula as the sample size. The sampling method used in this research is simply random., and is proportional to the size of the community.

$\mathit{n}=\frac{\frac{Z^2\mathit{pq}}{d^2}}{1+\frac{1}{N}\left[\frac{Z^2\mathit{pq}}{d^2}-1\right]}=\frac{\frac{{1.96}^2\times 0.5\times 0.5}{{0.5}^2}}{1+\frac{1}{6208}\left[\frac{{1.96}^2\times 0.5\times 0.5}{{0.05}^2}-1\right]}\approx 362$

1.5. Methods and tools of data collection

In the current research, the main tool of data collection in the field section included a semi-structured interview (in the qualitative section) and a researcher-made questionnaire based on a five-point Likert scale (in the quantitative section). The analysis of the findings was done in the qualitative part with MaxQDA software and in the quantitative part with EXCEL, SPSS, and LISREL software.

1.6. Demographic characteristics of the quantitative part

2. Results

Figure 1 Figure 2

Figure 1. Validation output of the model with partial least squares method.

Figure 2. Significance of relationships between variables with partial least squares method (bootstrapping).

Based on the observed path coefficient and the value of the t statistic (bootstrapping), the relationships of the variables can be interpreted as follows:

The impact coefficient of clinical effectiveness on evidence-based performance evaluation has been obtained as 0.303. Also, the value of the t statistic is 3.344. Therefore, it can be claimed with 95% confidence: that clinical effectiveness has a positive and significant effect on evidence-based performance evaluation.

The impact coefficient of employee requirements on evidence-based performance evaluation has been obtained as 0.317. Also, the value of the t statistic is 3.626. Therefore, it can be claimed with 95% confidence: that employee requirements have a positive and significant effect on evidence-based performance evaluation.

The impact coefficient of strategic planning on evidence-based performance evaluation has been obtained as 0.279. Also, the value of the t statistic is 2.738. Therefore, it can be claimed with 95% confidence: that strategic planning has a positive and significant effect on evidence-based performance evaluation.

The impact coefficient of the organization’s mission statement on evidence-based performance evaluation has been obtained as 0.391. Also, the value of the t statistic is 4.543. Therefore, it can be claimed with 95% certainty: that the organization’s mission statement has a positive and significant effect on evidence-based performance evaluation.

The coefficient of patient-centered impact on evidence-based performance evaluation has been obtained as 0.341. Also, the value of the t statistic is 3.544. Therefore, it can be claimed with 95% confidence: that patient-centeredness has a positive and significant effect on evidence-based performance evaluation.

The impact coefficient of human resource empowerment on evidence-based performance evaluation has been obtained as 0.289. Also, the value of the t statistic is 2.997. Therefore, it can be claimed with 95% certainty: that human resource empowerment has a positive and significant effect on evidence-based performance evaluation.

The effect coefficient of satisfaction on evidence-based performance evaluation has been obtained as 0.374. Also, the value of the t statistic is 3.990. Therefore, it can be claimed with 95% certainty: that obtaining satisfaction has a positive and significant effect on evidence-based performance evaluation.

The impact coefficient of accountability governance on evidence-based performance evaluation has been obtained as 0.303. Also, the value of the t statistic is 3.049. Therefore, it can be claimed with 95% certainty that accountability governance has a positive and significant effect on evidence-based performance evaluation.

The impact factor of support services on evidence-based performance evaluation has been obtained as 0.707. Also, the value of the t statistic is 908.9. Therefore, it can be claimed with 95% confidence: that support services have a positive and significant effect on evidence-based performance evaluation.

The coefficient of employee-oriented impact on evidence-based performance evaluation has been obtained as 0.356. Also, the value of the t statistic is 3.649. Therefore, it can be claimed with 95% confidence: that employee-centered has a positive and significant effect on evidence-based performance evaluation.

The coefficient of the impact of service quality and safety on evidence-based performance evaluation has been obtained as 0.459. Also, the value of the t statistic is 6.589. Therefore, it can be claimed with 95% certainty: that service quality and safety have a positive and significant effect on evidence-based performance evaluation.

The coefficient of the impact of hospital management on evidence-based performance evaluation has been obtained as 0.317. Also, the value of the t statistic is 3.586. Therefore, it can be claimed with 95% certainty: that hospital management has a positive and significant effect on evidence-based performance evaluation. The impact factor of accountability on evidence-based performance evaluation has been obtained as 0.515. Also, the value of the t statistic is 7.404 Therefore, it can be claimed with 95% certainty that accountability has a positive and significant effect on evidence-based performance evaluation.

3. Discussion and conclusion

A hospital is one of the important social organizations of any society that deals with human life and health, Weakness in evaluating its performance causes a delay in timely treatment and disease progression or death, and weakness in evaluating the performance of hospitals is an important factor. It is due to the increase in costs and the wastage of human and financial resources. Therefore, hospital managers, especially teaching hospitals, to manage this important and sensitive organization and overcome challenges and problems, have to turn to and evaluate evidence-based performance in the organizational unit. They are under their management to achieve an accurate evaluation of the performance and improvement of clinical efficiency and effectiveness of hospitals with the help of available evidence. In developed countries, hospitals account for about 40%, and in developing countries up to 80% of the costs of the treatment sector, so how to evaluate the performance and implement the results can be of particular importance. The lack of performance evaluation not only leads to an increase in medical costs, but also neglecting the provision of primary health care seriously endangers the health of society, on the other hand, providing it, in addition to ensuring and providing health, full efficiency of medical institutions at a reasonable cost and for the performance evaluation system to be more effective, it should be based on hospital evidence so that more favorable results can be obtained Sang and Sanyang (2016). To be aware of the level of desirability of their activities, especially in a complex and dynamic environment, every hospital has an urgent need for a performance evaluation system, and this performance evaluation is used as a process to judge the efficiency of predetermined programs. There are special tools and templates to be able to improve the quality of health services and improve the performance of clinical services, increase productivity, make the best use of medical health facilities and customer-oriented medical health units, reform the processes and economic management structure, and compile the most important indicators to achieve quality improvement. This is hospital evidence. Currently, the health sector needs an effective cost intervention for the best use of the monetary value of resources, and considering the importance of performance evaluation in determining the effectiveness of interventions for health care, evidence-based performance evaluation is inevitable, Sang and Sanyang (2016).

Future researchers are suggested to rank the dimensions and components of this model with multi-criteria decision-making techniques.

Based on the obtained results, it was found that clinical effectiveness has a positive and significant effect on evidence-based performance evaluation. These results are in agreement with the findings of Mossadegh Rad and Dahnavi (2018), which showed the percentage of bed occupancy, the average length of stay of patients, the distance between bed rotations, and the percentage of patient mortality were the most used performance indicators in the evaluation of hospitals. In most studies, the methods of data envelopment analysis and Pabon Lasso have been used to measure the efficiency of hospitals. The efficiency of hospitals in most of these studies has been reported as low to moderate. In the studies conducted using systematic performance evaluation models such as the models of the European Foundation for Quality Management and Malcolm Baldridge, the score related to the dimension of results was in most cases lower than the dimension of enablers. And Hosseinpour et al.‘s findings (2018), showed that 172 (94%) participants were male. The average age and history of the subjects were 45.28 and 19.30 years, respectively. The lowest score was related to the item “Using academic journals” (56.52%). While the managers relied the most on “Programs of the Ministry of Health” (80.98%). The average use of scientific research evidence, hospital information and statistics, national development programs, experimental and professional evidence, ethical-behavioral evidence, and evidence related to stakeholders is 59.70, 62.43, 75.30, 71.36, and 83, respectively. 71.00 and 73.00% were congruent and consistent. Evidence-based performance evaluation policy in recent years has tried to replicate the success of evidence-based medical and hospital performance evaluation approaches to achieve high-quality evidence-based health care and performance evaluation together. Considering hospitals are among the most complex organizations the management of such organizations is very difficult and highly sensitive. Consensus in using the evidence-based performance evaluation approach for the effective and efficient management of hospitals, especially teaching hospitals, is indispensable and undeniable.

Based on the obtained results, it was found that employee requirements have a positive and significant effect on evidence-based performance evaluation. These results are in agreement with the findings of Sang and Sanyang (2016), who showed that the performance of the hospital in the use of resources can be measured with specific indicators. It provides a realistic assessment of the current situation and a strategy for more effective use of healthcare services. Out of the total of 8 centers under study, 4 centers (50%) were located in the fourth district, 1 center (50.12%) was located in the third district, 3 centers (50.37%) were located in the second district, but no hospital was located in the first district. The findings of Bavular and Erosova (2016), showed that the average scores obtained from the survey of experts in the proposed model about the proposed mission statement were 4.07 (out of 5 scores), the average score of the clinical perspective was 16.68, and the patient’s perspective was 15.5., the perspective of internal processes was 14/86, the financial perspective was 14/78, and the perspective of employee growth was 15/41. The score of strategy for continuously improving the quality and safety of healthcare services is 4.9, optimal use of existing facilities and resources is 4.56, continuous and group effort to satisfy clients is 4.54, and responsibility for the health and safety of employees and the environment is 37. It has been 4/In total, 31 indicators were presented for 5 scenarios, one of which was removed from the final model. The significance level of the t-test at the 95 levels was less than 0.05, which means it is consistent. Therefore, hospital managers should benefit from the best possible evidence in the field of evaluating the performance of healthcare organizations, and their training should be based on the best evidence of healthcare management, which will link evidence-based learning and scientific healthcare management and will act as the engine of learning organizations.

Based on the obtained results, it was found that strategic planning has a positive and significant effect on evidence-based performance evaluation. These results are in agreement with the findings of Brown (2016), which showed that the evidence-based approach is effective in reducing the severity of nausea after surgery. The patients in the test group had less severity of nausea than the patients in the control group. With the findings of Jabari et al. (1398), which showed implementation challenges, seven themes and fifteen sub-themes were obtained. The inherent weaknesses of the performance-based payment plan are weakness in training and educational support, weakness in employee participation, weakness in information and communication technology, deficiencies and weaknesses in laws and regulations, unfavorable conditions of the public sector, and special conditions governing public hospitals. If the level of performance evaluation only includes people, as is common in human resource management departments today, the evaluation of employees’ competence is done with different criteria in organizations. The organization, people, or organizational unit, although they seem to do the work, are only a part of the whole system, and the conditions of its other components should also be considered. Paying attention to the comprehensive criteria and the strategies and ideals of the organization is one of the accessories of a comprehensive performance management system. Such an approach in performance evaluation will be a real, justice-oriented, reliable, reliable, progressive and dynamic evaluation.

Based on the obtained results, it was found that the organization’s mission statement has a positive and significant effect on evidence-based performance evaluation. These results are in agreement with the findings of Rezaei Manesh (2019), which showed that the scores based on the 9 EFQM model are leadership, policy and strategy, processes, customer results, employees, resources and companies, community results, community results, and key results. The order has been obtained. It is consistent. The evaluation of devices and employees based on the new approach compared to the traditional approach has fundamental differences in various dimensions. The consequence of having an evaluation system based on a new perspective is to improve the functioning and ultimately the effectiveness of the organization’s activities. If the government agencies feel with all their heart that the basic goals related to the evaluation are in line with the growth, development, and improvement of their performance and activities, and the phenomenon of judgment and wrist-watching has no place in it, then the organizations and their employees will welcome them. They establish an evaluation system and regularly try to improve its mechanisms. The result of these efforts is the creation of a self-evaluation system in organizations, which will result in the growth, development, and improvement of performance and ultimately the realization of organizational goals.

Based on the obtained results, it was found that patient-centeredness has a positive and significant effect on evidence-based performance evaluation. These results are in line with the findings of Yahyai et al. (1398) who showed that by reviewing the BSC views and the relationship between their goals, the view of customers was at the best level, and the views of processes, finance, and growth, and learning were at the lowest level, respectively. “Increasing employee satisfaction” and “encouraging innovation” as the most basic goal and “patient satisfaction with the physical environment” was placed at the highest level of the strategy map. And with the findings of Mossadegh Rad and Dehnavi (2018), showed that the percentage of bed occupancy, the average length of stay of patients, the distance between bed rotations, and the percentage of patients’ mortality were widely used performance indicators in the evaluation of hospitals. In most studies, the methods of data envelopment analysis and Pabon Lasso have been used to measure the efficiency of hospitals. The efficiency of hospitals in most of these studies has been reported as low to moderate. In the studies conducted using systematic performance evaluation models such as the models of the European Foundation of Quality Management and Malcolm Baldridge, the score related to the dimension of results was in most cases lower than the dimension of enablers. Health system performance evaluation can be used to form a common understanding of prioritization to strengthen healthcare systems, provide a platform for dialogue between programs and between different departments, and create a common understanding to communicate between activities that affect health outcomes.

Based on the obtained results, it was found that human resource empowerment has a positive and significant effect on evidence-based performance evaluation. These results are in agreement with the findings of Nouhi and Shakuri (2015), which showed that most facilitators from the nurses’ point of view are related to holding refresher courses on methods of analyzing and holding evidence, and most obstacles are related to implementation obstacles, including easy access to research information. It was daily and efficient. There was a significant and inverse relationship between the score of barriers and facilities, and no significant relationship was found between executive barriers and facilities with the contextual variables of age, gender, and education.

Based on the obtained results, it was found that satisfaction has a positive and significant effect on evidence-based performance evaluation. These results are consistent with the findings of Chang et al. (2020), and Mumford et al. (2018). Evaluating the performance of healthcare systems helps health decision-makers and politicians to be accountable and responsible for their decisions. The history of performance evaluation of the healthcare system goes back to the decade before 2000. So far, different performance evaluation models have been presented with different goals and approaches, and different countries each have different experiences in formulating and applying different evaluation models.

Based on the obtained results, it was found that accountability governance has a positive and significant effect on evidence-based performance evaluation. These results are in line with the findings of Nasrullah Pour Shirvani and Tahmasabi (1395) who showed that in each country, following the political, economic, and social structure and based on the goals expected from the health system, there is a need to design performance evaluation models and due to the need for accountability transparency. This performance evaluation should be designed at different levels of health and treatment so that each unit accepts responsibility for its activities and is consistent. Evidence-based medicine has been born out of a situation in which the gap between “research” and “care delivery” is deepening every day. In simple words, the distance of clinical people from the application of research results in providing care was increasing every day. Evidence-based medicine was born to fill this gap. Also, modern medicine is faced with the influx of information, especially in the age of communication, without the possibility of analyzing all the published materials, which on the one hand are a good source for clinicians, and on the other hand, may cause them confusion. In this way, the need to create appropriate methods for searching, evaluating, aggregating, and reviewing existing data and generating new data based on previous data and how to use them becomes more tangible.

Based on the obtained results, it was found that support services have a positive and significant effect on evidence-based performance evaluation. These results are in agreement with the findings of Zakaria Kiaei et al. (1394) who showed that the overall average of evidence-based performance barriers among nurses was 3.07. Based on the evidence and gender, there was no significant statistical relationship, but a significant statistical relationship was observed between the dimension of the organization and the age, type of employment, and work experience of the nurses. And with the findings of Mumford et al. (2018), showed a low response rate., the lack of in-depth power in health care, fundamental differences between the health system and service delivery, knowledge and clinical expertise in the care, and patient values during care as the basic principles of evidence-based care in Swedish private hospitals Chang et al. (2020). They took it. It is consonant and consistent Zakaria Kiaei et al. (1394). A review of sources and scientific works shows that there is a big difference between the performance of clinical people, which reflects a deep gap between research and care delivery. In other words, clinical people do not use research results enough to provide care. Dozens of valid documents can be presented to prove this claim. In summary, in many clinical situations, we do things we should not do and in other situations, we do not do things we should Mumford et al. (2018). Most of the time, we do not have strong scientific evidence to prove the correctness of our clinical decisions and in most cases, we cannot prove that our clinical decisions benefited the patients or not Shirvani and Tahmasabi (1395).

Based on the obtained results, it was found that employee-oriented has a positive and significant effect on evidence-based performance evaluation. These results are in line with the findings of Miniong et al. (2019) who showed that continuous scientific progress along with the changing status of clients and patients requires that nurses can diagnose patients’ problems by combining their technical skills and professional knowledge based on scientific evidence data and solve these problems in the form of evaluation and care programs. The findings of Chang et al. (2020) showed that the results obtained from patient care using evidence-based methods were 30% lower than traditional care and also increased job satisfaction in the nursing staff of hospitals that value nursing quality. Unfortunately, people usually reach a certain belief based on some evidence and then look for confirmation of their belief in the mass of information, and we know that even if that belief is wrong, it is quite possible to find evidence to confirm it among this amount of information. In the meantime, evidence-based practice is a new and different approach that teaches us to search and criticize information first and then form our beliefs. Evidence-based practice is the informed, clear, and correct use of the most valid evidence available to make decisions about patient care.

Based on the obtained results, it was found that the quality and safety of services have a positive and significant effect on evidence-based performance evaluation. These results are consistent with the findings of Zinta (2020), which showed that the designed performance evaluation model includes 15 categories. Among these 15 categories, five categories are related to inputs, and five categories are related to processes. Research outputs and achievements, consequences and effects, efficiency, action research and encouragement, and support are also five other categories of the performance evaluation model of the research and research groups of the education departments of Paraguay. Erstad’s findings (2015), showed that there is a significant difference between the evaluation scores of employees on the performance of managers of health and treatment networks, the self-evaluation scores of managers of health and treatment networks, and also between the evaluation scores of employees on the performance of hospital managers in two provinces. There was (p < 0.001). Based on the findings of the research and the comments of managers, a model for evaluating and improving the performance level of managers of health and treatment networks was presented. The accreditation program is a huge development in the management of health services in the country, which provides the link of senior management with the provision of effective medical services, and is one of the most reliable evaluation models based on quality and safety, with increasing global acceptance in the health sector, in harmony with other The priorities of the relevant ministry, such as clinical governance, patient safety, and the charter of patient rights, along with educational accreditation standards and paying attention to research infrastructures, especially in the field of observing patient safety and rights, and improving the quality of services, are a new way to ensure the proper functioning of organizations. The provider of health services has been placed beyond the practitioners of this field.

Based on the obtained results, it was found that accountability has a positive and significant effect on evidence-based performance evaluation. These results are in agreement with the findings of Zakaria Kiaei et al. (1394) who showed that the overall average of evidence-based performance barriers among nurses was 3.07. Based on the evidence and gender, there was no significant statistical relationship, but a significant statistical relationship was observed between the dimension of the organization and the age, type of employment, and work experience of the nurses. And with the findings of Mumford et al. (2018), showed a low response rate., the lack of in-depth power in health care, fundamental differences between the health system and service delivery, knowledge and clinical expertise in care, and patient values during care as the basic principles of evidence-based care in Swedish private hospitals. It is consistent and compatible. Providing needed care is one of the basic duties of professional nurses in today’s world. Nurses can provide optimal care to the community if they adapt to the complexities of the healthcare environment and changing demands. Changing the current nursing model from making decisions based on personal experiences and opinions to using more scientific and research approaches has a significant impact on patient care and improving its quality. The legal and ethical responsibility of nurses, as the largest group of care providers in public and private hospital departments, is to protect patients against unscientific practices. This important thing will not be possible except by institutionalizing an approach based on valid evidence.

Disclosure statement

No potential conflict of interest was reported by the author(s).