Development of performance evaluation indicators for pre-hospital emergency centers

Introduction: Prehospital emergency health care plays an important role in saving lives. Proper performances of different parts of this system result in the rapid and timely deployment of an ambulance in patient’s place and prevention of death and disability. Thus, this research was conducted to compile performance evaluation indicators for pre-hospital emergency centers in 2017. Methods: This study is a qualitative-quantitative research conducted in 2017. In order to compile the indexes for evaluating the performance of pre-hospital emergency centers, the study was done in two phases. In phase one of the study, primary items and their fields were identified according to the recent literature. In the second phase, Delphi technic in three rounds was used to finalize the items and the fields. In the first round of Delphi technic, the identified items and fields were given to experts in forms of checklist. The items and fields with average of >4 and standard deviation of <1 were confirmed, items with average of <2 and standard deviation of <1 were removed, and other items were randomly passed into round two. In the second round, all the items with average of >4 and standard deviation of <1 were confirmed, items with an average of <3 and standard deviation of <1 were removed, and other items were randomly passed into round three. In round three, only items with average of >4 and standard deviation of <1 were confirmed, and other items were removed. Results: The results of the study showed that 9 items in field of facilities and physical space, 10 items in field of communication, 10 items in field of ambulance, 8 items in field of human resources, 9 items in field of regulations and protocols, 3 items in field of storing equipment in the center, and 3 items in field of training were identified. Conclusion: Considering the identification of seven effective factors in improving the quantitative and qualitative level of pre-hospital emergency services, it is highly important for authorized managers and decision-makers to improve all necessary factors.


INTRODUCTION
Every organization needs a system to raise awareness of its services and activities quality, especially if it is a dynamic and complex organization. Moreover, lack of evaluation and control in a system may harm the organization itself. 1 Evaluating the performance of an organization is a tool, not only for the organization to know the efficiency of the staff but also for the staff to aware about their own positions. If this tool is well designed and applied, it can be helpful in improving, training, encouraging and punishing, and fair payment. Thus, this study reviewed the role and importance of pre-hospital emergency centers. 2 Pre-hospital emergency system includes an important part of presenting health service 3,4 in critical conditions outside the hospital and focuses on prevention of acute death and elimination of threatening conditions with rapid diagnosis and prompt treatment. 5 Medical emergency system, which is the most important factor in eliminating death, is the front line of healthcare centers 6 since this system should provide health services according to global standard protocols when dealing with patients. There are some reports showing 12% of the world's disease burden is due to accidents. Regardless of their reasons and concepts, accidents have tremendous effects on the health systems that provide required care and logistics for the victims. 7 The pattern of diseases have changed in recent years. As an example, the reports of Ministry of Health show that death caused by cardiovascular diseases includes all death in the recent decade. Therefore, risk management and emergency surgery increasingly became interesting subject for further researches in Iran. 8 Pre-hospital medical emergency services are defined as services bridging the health needs of people outside the hospital. The needs include taking care of life-threatening events, transmitting patients and injured people to health care centers, and being ready to do missions in events with the risk of injury. The more proper, more correct, and faster are these services, the lower will be the number of death and the higher will be people's trust to our health system. Appropriate performance of different parts of the emergency system results in rapid and welltimed ambulance deployment to the patient's place to prevent death and disability. The success of the system depends on various factors, such as the competence of the staff, trained personnel, facilities, concordance, and communication system. 9 Bahrami et al. in their research on evaluating pre-hospital emergency services in Yazd in 2009 found that only 14.3% of emergency centers have enough personnel and none of the ambulances have all 52 types of the equipment. 9 In order to improve the services, every country should evaluate its emergency medical service (EMS) and start improving its quality which can be reasonably achieved. Considering the importance of pre-hospital emergency centers in saving people's lives, this study was conducted in order to inform authorized managers in Yazd Province on level of standards of pre-hospital emergency services, determine the weak and strong points of each unit, as well as provide proper context to plan promotion of quantitative and qualitative level of these services.

MATERIALS AND METHODS
This quantitative-qualitative study was conducted in 2017 in two phases in order to compile the indexes for evaluating the performance of pre-hospital emergency centers.

Phase One: Literature Review
A checklist was designed by interviewing 30 experienced experts and reviewing researches about this topic, including modified standards of pre-hospital emergency included standards of ambulance and emergency centers equipment (Extracted from Iran National Standards and industrial researches, no. 4373), performance reports of pre-hospital emergency centers, inspection programs approved in emergency centers and drafts of pre-hospital emergency standards in Ministry of Health (No. 25921/401/d).Phase Two: Delphi Technic In this phase, 20 experts including managers, directors, and staff of pre-hospital emergency centers in the province were selected as the target group of the study. Delphi process was conducted in three rounds.

Round one:
The designed checklists for evaluating the performance of pre-hospital emergency centers in the province were given to the experts. The experts individually studied the mentioned items and fields and expressed their opinions in five-option Likert scale { (5 -highly proper) to (1 -completely improper)}. In the first round of Delphi, the identified items and fields with an average score of >4 and standard deviation of <1 were confirmed, items with average score of <2 and standard deviation of <1 were removed, and other items were passed into the second round.
Round two: In this round, checklists were prepared individually and given scores for each item in the previous round, and the average score were given to the experts. In the second round, all items with average score of >4 and standard deviation of <1 were confirmed, and items with average score of <3 and standard deviation of <1 were removed.
Round three: Only items with average score of >4 and standard deviation of <1 were confirmed and other items were removed. This study was approved by ethics code IR.SSU. SPH.REC.1394.9 in Yazd Shahid Sadoughi University of Medical Sciences.

RESULTS
The results of the study showed that 9 items in field of facilities and physical space, 10 items in field of communication, 10 items in field of ambulance, 8 items in field of human resources, 9 items in field of regulations and protocols, 3 items in field of storing equipment in the center, and 3 items in field of training were identified.
According to table 1, 8 main fields were identified. These fields included building (with 6 items), hoteling (with 3 items), communicating system (with 6 items), ambulance (with 7 items), human resources (with 11 items), regulations and protocols (with 8 items), storing equipment in the center (with 3 items), and training in the center (with 5 items).
The findings in table 2 show that building field and its four items with average score of >4 and standard deviation of <1 were confirmed and other items were passed to the second round. Hoteling field and one of its items with average score of >4 and standard deviation of <1 were confirmed and two other items were passed to the second round. Three items of communication field were confirmed and other items were passed to the second round. In ambulance field, five items were confirmed, one was removed, and one item was passed to the second round. In human resources field, three items were confirmed, two items were passed to the second round, and others were removed. In storing equipment field, two items were confirmed and one item was removed. Finally, in training field, three items were confirmed, one item was removed and two other items were passed to the second round.
Findings of Table 3 indicates that 9 items in the field of building and physical facilities, 5 items in the field of communication, 5 items in the field of ambulance, 5 items in the field of human resources, 5 items in the field of regulations and protocols, 1 item in the field of storing equipment and 1 item in the field of training were confirmed with the average score of >4 and standard deviation of <1.
As seen in table 4, two items in the field of communication with the average score of >4 and standard deviation <1 were confirmed.

ORIGINAL ARTICLE
Findings in Table 5 shows that total 9 items in the field of building and physical facilities, 10 items in field of communication, 10 items in the field of ambulance, 8 items in the field of human resources, 9 items in the field of regulations and protocols, 3 items in the field of storing equipment, and 3 items in the field of training were confirmed.

DISCUSSION
According to the literature review and experts' opinion, seven factors were selected as effective factors in pre-hospital emergency centers in Yazd Province. In this study, the field of human resources was identified as an index for evaluating pre-hospital emergency centers. In a study by Pakhere et al. on ranking the effective factors on the readiness of pre-hospital emergency centers in the view of operational personnel in Mazandaran, human resources were identified as effective factor. 18 Another study in Tehran showed that 100% of kermanshah emergency centers lack personnel and solutions for providing sufficient human resources, operator, and crew for each center as well as solving multi-shift problem were proposed. 19 The mentioned studies are compatible with this study.
Another factor to increase the efficiency of emergency centers is sufficient equipment of the centers in Yazd Province. Iri et al., in their study on defining the concept and challenges if service providing in pre-hospital emergency centers, considered lack of sufficient equipment and facilities as a critical challenge of the emergency centers in providing services. 20 Findings of a study by Bahrahi et al. on evaluating the performance of pre-hospital emergency centers in Yazd Province indicated that none of the present emergency centers owned standardized equipment. The findings of the abovementioned studies are consistent with this study.
Another important index in evaluating the emergency centers is the field of regulations and protocols. Adnet study which was conducted in France in 2004 indicated that training-related regulation could be a critical step to integrate health care services. 21 In the study by Iri et al., approved regulations was similarly effective in patients' satisfaction. Another effective index on the performance of the emergency centers is the equipment and improvement of the ambulances. The results of a study done in Suskatchewan State in the USA showed that financial issues for providing required equipment for ambulances were considered as a priority in pre-hospital emergency centers there. 22 Vaitkaitis reviewed the most important critical problems in emergency services in Lithuania. The findings of his study indicated that age of present ambulances and loss of integrating standard for medical education were effective factors resulting in a weak performance of emergency centers in Lithuania. 23 A challenge for providing prevention medical services in Iri's study (2015) in Mazandaran was inappropriate cooling and heating systems in ambulances, age of ambulances, lack of integrity in the fleet of ambulances, inappropriate arrangement of equipment in ambulances, time-consuming repairing of ambulances, lack of facilities, low quality of equipment, lack of cutting and dispensing devices, and lack of equipment for transferring patients from the upper floors of buildings. The results of the mentioned studies are compatible with the results of this study.
In designing pre-hospital system, appropriate communicative devices should be provided for all EMS service-givers as well as all EMS personnel. This study identified the field of communication as an effective index. Bahadori prioritized the effective factors on the readiness of pre-hospital emergency centers and introduced communication as the most effective factor. 24 Mann considered applying IT tools such as telemedicine and GIS as an effective factor in managing health care, and accessing and controlling effective communication. 25 Askari et al. studied designing a model for evaluating the responsiveness of the health system to accessing primary services and equipment. 26 The results of these studied were compatible with results of this study.
The field of building and physical facilities was another effective factor in the performance of pre-hospital emergency centers. The results of a study by Moti et al. on prevalence of stressors in male technicians of the emergency centers proved that the most important stressors in male technician were physical stressors, the most important of which were lack of enough time for resting, lack and loss of appropriate facilities, lack of a suitable place for resting, unsatisfactory of welfare facilities, and noise pollution in resting places. This study is compatible with the mentioned study.
Training is another important factor in the performance of pre-hospital emergency centers ,as mentioned in the researches of Bahadori and Haghani. Bahadori recognized training and regulations as effective indexes. 23 Haghani concluded that unawareness and weak performance of the emergency center's personnel can be solved by constant trainings. 27

CONCLUSION
Regarding the identification of the seven effective factors in the improvement of quantitative and qualitative level of pre-hospital emergency centers in Yazd province, improving evaluation system, establishing an approved organizational chart, leveling pre-hospital emergency centers' staff, upgrading equipment, continuing training, and improvement of communication systems considered necessary. Finally, it is suggested to review personnel's ideas as owners of pre-hospital emergency processes understanding their challenges inside and outside the organization. A comprehensive view can be codified and presented as guidelines to the decision-makers.

RESEARCH LIMITATIONS
The remoteness of some emergency centers from the provincial capital and the timing of the information gathering process were subject to research constraints.