1. Introduction

1.1. Background

Quality management uses management techniques and tools in quality assurance and control of processes to achieve consistent quality of products and services. Many definitions of quality can be found in the TQM literature (Goetsch & Davis, 2014). In Lebanon, the healthcare system is both driven and designed by stakeholders that control the factors and outcomes of numerous healthcare services. As to the external quality bodies they form a large proportion of the stakeholders’ share. They are represented by private external quality bodies, as well as individual free lancers, whose main functions are to assess, audit and emit certification services.

1.2. Problem

This article is going to address a major problem facing the Lebanese Health care system that’s briefed by the challenge of establishing an overall Total Quality Management system inside hospitals. The problems here are the challenges followed by a weak EQA in hospitals, like the impact of a weak EQA on stakeholders, as well as the impact of EQA on the overall performance of a Hospital. A weak EQA is to impact patients, employees as well as a stockholders/owner. Research questions: How would the external-quality bodies affect the Lebanese healthcare system in increasing their quality of services? How would the external-quality bodies influence the Lebanese healthcare market in increasing patient confidence in Lebanese healthcare services?

1.3. Aim

The aim of this article is to cast the light on the importance of the external quality bodies in improving healthcare services in Lebanon, whether in large hospitals or medical institutions, or even polyclinics and wellness centers. By doing so, this research’s other goal is to mobilize the awareness of the local healthcare market on the crucial role of the external quality bodies. Thus, the tangible solutions that the researcher stress on will enlighten both professionals and practitioners from the Lebanese healthcare community in terms of quality management and transference of knowledge.

1.4. Significance

By focusing on key characteristics of the external quality factors the researcher evaluates a hidden, and often overlooked element that greatly contributes in improving services and working environment within hospitals. With such evaluation comes an appreciation of what can be achieved when quality is celebrated by all team members. This is particularly significant in the Lebanese context where fewer studies exist on the effect of external quality bodies in healthcare. Moreover, this research will help practitioners as well as actors strengthen their collaboration between different health care external quality stakeholders.

2. Literature Review

• Quality Management System (QMS)

QMS meaning “quality management system” is an accumulation of business forms concentrated on reliably meeting client prerequisites and improving their satisfaction. It is lined up with an association's aim and strategic direction. It is communicated as the hierarchical objectives and yearnings, strategies, forms, archived data and assets expected to actualize and look after it. Early QMS underscored unsurprising results of a modern product production line, utilizing straightforward insights and arbitrary inspecting (Robson & McCartan, 2016).

By the twentieth century, work inputs were normally the most expensive contributions to most industrialized societies, so focus moved to group participation and dynamics, particularly the early motioning of issues by means of a continual improvement cycle. In the 21st century, Quality Management System has tended to unite with manageability and straightforwardness activities, as both financial specialist and consumer loyalty and perceived quality is progressively attached to these variables. Of Quality Management System routines, the ISO 9000 group of measures is likely the most generally executed around the world – the ISO 19011 review routine applies to both, and manages quality and manageability and their coordination (Groenewoud et al., 2015).

As of Robson & McCartan (2016), Different Quality Management System, for example natural step, center around manageability and sustainability issues and accept that other quality issues will be decreased as aftereffect of the methodical reasoning, straightforwardness, documentation and indicative control. The expression QMS were developed in 1991 by Ken Croucher, an English administration expert taking a shot at structuring and actualizing a conventional model of a Quality Management System inside the IT business.

• External Quality Assurance

Definition

Lewis et al. (2006) states that “A rash of external inspection is affecting the delivery of health care around the world. Governments, consumers, professions, managers, and insurers are hurrying to set up new schemes to ensure public accountability, transparency, self-regulation, quality improvement, or value for money. But what do we know of such schemes’ evidence base, the validity of their standards, the reliability of their assessments, or their ability to bring improvements for patients, staff, or the general population? In short, not much.” The standards, measurements, and results of management systems have not been, and largely cannot be, subjected to the same rigorous scrutiny and meta-analysis as clinical practice (Mazzocato et al, 2010).

No one has published a controlled trial, and there are too many confounding variables to prove that inspection causes better clinical outcomes, although there is evidence that organizations increase their compliance with standards if these are made explicit. But experience and consensus are gradually being codified into guidelines to make external quality systems as coherent, consistent, and effective as they could be. Much of this consensus is ignored by those who develop and operate new programs. In Britain there has been no consistent central strategy to support or coordinate existing external assessment programs. The NHS has introduced new statutory bodies and triggered more formal programs of visiting and assessment. Each brings a burden of inspection and requires resources for development, but responsibility for ensuring the integration, consistency, and value of such programs has not been defined. This article describes the growth of external assessment and the issues it raises around the world, particularly in Britain for example (Mazzocato et al, 2010).

Van Schoten et al. (2016) Report created by External Quality Assessment (EQA) providers serve as a major feedback tool towards the participating laboratories. They support the pedagogic role of EQA and are often used by auditors to follow up laboratory quality, certainly in the light of eventual accreditation. Different EQA providers summarize the statistical evaluation and their findings in various types of reports. In a first instance, participating laboratories should receive, as soon as possible after an EQA round closing, a confidential individual report detailing their own performances (Nicolay et al., 2012).

The report should be as clear and comprehensive as possible and contain the assigned values for each of the parameters that were included, limits of acceptability and evaluation for each of the laboratory’s result. Ideally, it would contain additional information to support evaluation, like the number of laboratories involved in the evaluation and details about the distribution of data reported by all the participants. As such, the report allows the participating laboratory to compare its results for each analyte with those of other participants. In addition to individual reports for each participant, summary reports containing general and anonymized information on method performance, variability and bias for different analytes could be included at the end of each round (Van Schoten et al., 2013).

EQA Implementation

As of Talib et al. (2011), Many countries have voluntary and statutory mechanisms for periodic external assessment of healthcare organizations against defined standards, and some have been systematically compared. They are all meant to assure or improve some elements of quality, but they are usually run by different organizations without national coordination to make them consistent, mutually supportive, economical, and effective. Broadly, these mechanisms include variants on five approaches. The International Organization for Standardization provides standards against which organizations or functions may be certificated by accredited auditors. These have been applied in health care, specifically to radiology and laboratory systems, and more generally to quality systems in clinical departments. The Baldrige criteria have evolved into national and international assessment programs such as the Australian Business Excellence Model (www.aqc. org.au/) and the European Foundation for Quality Management (Talib et al., 2011).

Programs of external review should make their standards, survey protocols, decision criteria, and results available to the public at “little or no cost. “The organizations themselves should work towards a common set of standards, coordinate their activities to avoid conflict and duplication, and commit themselves to a national quality forum (Jayatam et al., 2010).

This forum aims to devise a national strategy for measuring and reporting healthcare quality and in 1999 began to standardize performance measures for the nation’s 5000 acute general hospitals.15 In 1999 the US inspector general of the Department of Health reviewed the external quality oversight of hospitals that participate in Medicare (Jayatam et al., 2010).

She concluded that voluntary “collegiate” accreditation by the Joint Commission on Accreditation of Healthcare Organizations and “regulatory” Medicare certification by state agencies had considerable strengths but also major deficiencies. She recommended that both systems should harmonize their methods, disclose more details of hospital performance on the internet, and be held more fully accountable at federal level for their performance in reviewing hospitals. An Australian taskforce recommended in 1996 that the government should formally acknowledge independent assessment programs that met defined criteria and should enable them to disseminate information about their processes and findings to the public (Guyatt, 2008).

Two years later an expert advisory group recommended “that accreditation or certification of healthcare organizations be strongly encouraged with incentives, or indeed made mandatory, but choice of accreditation/certification/award approaches be allowed.” In Scotland the Carter report on acute services recommended a single mandatory system of accreditation for hospitals and primary care. This should be patient centered, clinically focused, and complementary to internal quality improvement, and its explicit, measurable standards and reports should be in the public domain (Young, 2005).

• The Health Care System and TQM

Evolution of TQM in the Health care

Plsek and Wilson's (2018) inquire about gives important bits of knowledge on the best way to leave on framework change. Accordingly, one specific portion gives the contemporary guidelines in structuring a medicinal services framework that resounds with the requests of our age. It depends on outline diagrams from the American Establishment of Drug Advisory group on Nature of Medicinal services (Plsek and Wilson, 2018), that analyze the old and new methodologies:

Another spearheading insightful investigation is titled ''Making a recuperating situation'' and distributed in the Diary of Social insurance the board (Fotler et al., 2018); it accentuates both the job of the administration and the earth in parallel with patient-driven association. Referring to craft by Hutton and Richardson (1995), the creators see how condition can apply positive or negative impacts on patients as well as on medicinal services authorities also. Also, the creators attest that partners' frame of mind may regularly decide the results. Their calculated methodology is delineated in a diagram separated in four classifications (Fotler et al., 2018):

A- Environnemental Dimensions

B- Internal Responses

C- Behaviors

D- Outcomes.

It merits referencing that the two examinations were distributed right around two decades back when authoritative dimension the board in emergency clinics and healthcare services focuses were separating themselves from standard practices and strategies. To be sure, they uncover the goals of a framework inclined on receiving another theory and making ready of modernization (Valmohammadi & Roshanzamir, 2015).

According to Zu et al. (2010), Nowadays that expectation is made one stride further as the business is propped for significantly more development of its infrastructural administrations. The Harvard Business Audit is among the ongoing scholastic and the board establishments that declared the production of two titles on medicinal services: one is about technique and the second on authority. They give crisp points of view from specialists who endeavor to grow their core interest. The volume on initiative (Lee, 2018), for instance, incorporates a section on the best way to utilize an ''adjusted scorecard'' as a ''key QM'.

Factors of TQM and Organizational Performance

Disentangling the association will prompt the foundation of a framework of coordinated business capacities taking an interest as a group and supporting the vital vision of the organization (Sadikoglu & Olcay, 2014):

• Quality measurement and benchmarking: An organization must grasp solid acknowledgment and support of an all-out quality measurement and benchmarking plan. Quality projects should quantify the rate or the quantity of parts that veer off from the satisfactory so as to anticipate the repeat of an imperfection.

• Process management: This factor underlines enhancing forms, expanding quality dimensions, and raising efficiency per employees.

• Product design: Plan rehearses give a perfect beginning stage to the investigation of quality performance.

• Employee training and empowerment: Workers must be situated to an organization's reasoning of pledge to ceaseless improvement, be educated regarding organization objectives, and be made to feel part of the group.

• Vendor quality management: Numerous organizations presently support, from a certain point of view, the need to work all the more intimately with their providers.

• Customer involvement and satisfaction: Client service ought to be tended to from two principle zones: internal customer service and outside client certification.

3. Methodology

The study is being conducted in an area in which few, if any, preceding studies were undertaken. Case studies are described in diverse methods and a standard does no longer exist. However, a definition compiled from some of resources (Stone, 1978; Benbasat, 1984; Yin, 1984; Bonoma, 1985 and Kaplan, 1985) in Benbasat et al. (1987, p.370), runs as follows: A case study examines a phenomenon in its natural setting, using a couple of techniques of data collection to collect data from one or a few entities (people, groups or organizations). The limits of the phenomenon aren't clearly evident on the outset of the studies and no experimental control or manipulation is used.

According to our research goals, the researchers intend to analyze existing meetings thought to be probably appropriate for this research topic. So as to decide how the researchers can most successfully evaluate the need for External Quality Accreditation for Healthcare Organizations in Lebanon from Stakeholders Perspectives.

This tool is administered to meeting contributors in hospitals stated later-on. It is a key information collection tool. This tool has been verified via statistical means with information samples. The researchers describe the precise improvement and validation methods of the tool later-on in this section of the thesis.

This approach as clarified by Saunders et al. (2009) is associated with perceptions, knowledge and subjective discourses of the concept of the problem. It is tied in with social event non-numerical data by setting center gatherings and leading conferences maintaining in mind the end purpose to determine the perspectives and practices from people, experts, and government. Eisenhardt and Graebner (2007) concur that subjective research is more instructional and more extravagant in providing a comprehension to the examination running by the expert.

According to the chosen methodological type, Surveys questionnaires may be distributed over a specific populace of respondents working within the healthcare area focusing 60 managers working at the said area in North Lebanon.

As an example, estimate, this research will collect data from more or less 60 employees and managers that are working in 16 hospitals in Lebanon. Even though the trying out approach is a "sample random technique": wherein all populations of people are given the equivalent possibility of representation, this example will introduce a decent representation of the chosen populace in North Lebanon.

In proceeding with our methodology several visits, interviews and observatory analyses were conducted in these centers between the period of April 30 and May 19. Four doctors, managers, and health care officials were interviewed during these visits bearing in mind the following questions:

Qualitative research contributes to a knowledge of the human situation in distinctive contexts and of a perceived situation. However, there's no ideal designed study, and surprising events will continually appear. The primary problem is how many economic resources, effort and time the researchers in a study group are capable of put money into looking to understand the phenomena underneath study (Patton, 2002). Nevertheless, a researcher has to create the best study layout feasible, through accurate and considerate planning primarily based on current circumstances by identifying available resources.

Content analysis is a research technique for analyzing files and communication artifacts, which is probably texts of diverse codecs, photographs, audio or video. Social scientists use content analysis to study patterns in communication in a replicable and systematic way. One of the key benefits of the use of content analysis to research social phenomena is its non-invasive nature, in comparison to simulating social experiences or collecting survey answers.

4. Findings and Results

• Question 1: Faced Problems in EQM

Table 1

According to what’s displayed in the table above, the researcher showed all the problems collected throughout the 60 conducted interviews.

What are the adopted measures to prevent service and care-related problems?

According to the table above, the results showed that the adopted measures to prevent service and care-related problems in the Accreditation System. According to the interviews “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve. The accreditation is not just about standard-setting: there are analytical, counseling and self-improvement dimensions to the process. There are parallel issues in evidence-based medicine, quality assurance and medical ethics, and the reduction of medical error is a key role of the accreditation process. Hospital accreditation is therefore one component in the maintenance of patient safety. However, there is limited and contested evidence supporting the effectiveness of accreditation programs.”

Another interviewee noted that the Ministry of Public Health in Lebanon cited that “For the purpose of improving and updating the current hospital accreditation system in Lebanon, the Ministry of Public Health aimed to revise and develop new Lebanese hospital accreditation standards according to latest evidence and international best practices and also to comply with International Society for Quality in Healthcare (ISQua) requirements.”

Problems with TQM (related to employees)

TQM is likewise imagined to place a greater emphasis on self-control, autonomy, and creativity, anticipating active cooperation from personnel as opposed to mere compliance with the employment agreement. For Hill, participation is ‘the principal mechanism for enhancing hospital quality‘, one of the seven key concepts of TQM, alongside tougher elements including SPC. The interviewee argues that everybody, from the most senior manager at the health center to the ordinary office and other personnel, should take part within the process of figuring out and imposing enhancements. The task of top management is to ‘design a structure and establish a culture that will maximize the effective participation of all employees in the pursuit of quality. There are thus potential contradictions between increased staff influence over management decision-making, and the limited impact of employee involvement upon underlying organizational structures.’

What is some positive impact of TQM on Hospitals?

47.6% of the interviewees agreed that TQM positively affects the health center’s approaches. This consists of “continuous development, teamwork, training, top management dedication, and client focus. Non-stop improvement was the most considerable factor in explaining variance in implementing TQM concepts.”

He adds that “TQM was implemented in Lebanese hospitals at a level approximately less than 60%. The most implemented principle was customer focus, and the least implemented was continuous improvement.”

EQA and organizational communication with workers

The interviewees agreed that EQA and Organizational communication with employees is essential because it motivates the worker by promoting proper verbal exchange. Collaborating in an EQA scheme permits a laboratory to collect precious information, this data may be utilized in a selection of methods:

• Enables a comparison of performance between hospital departments

• Enables a comparison of performance between hospital sites

• Provides an early warning for systematic errors

• Indicates areas for improvement

• Provides evidence of quality

• Identifies training areas

• Detects equipment faults, identify reagent problems and review staff training

• Compares performance to different analytical methods

EQA and management and employment strategies (Talent Acquisition)

The majority of the interviewees said that EQA and skills acquisition are interrelated in the case of skills choice. A few hospitals are using the skills acquisition system as a part of their general EQA system.

Skills acquisition systems include tools that will help you:

• Build a candidate pipeline, to engage candidates and maintain them engaged over the acquisition lifecycle.

• Screen and select

• Onboard and engage

• Employers will need more than disparate or cobbled together equipment to successfully meet that type of demand. They’re additionally going to need to face out from the crowd and compete for skills like market share. And, they're going to want to outsmart the competition.

View on the extent of external quality on Accreditation needed for managerial implication

The following simple goals need to be accomplished in an external QA: 1. Determine the performance and effectiveness of the IA hobby in light of its charter, the expectancies of the board (generally represented by using an oversight body, along with an audit committee), executive management, and the CAE. Take into account the IA activity’s current needs and targets, in addition to the future direction and dreams of the company. Appraise the risk to the organization if the IA activity is performing at much less than an effective level or isn't in conformance to 1 or more of the requirements. 2. Provide an opinion at the IA activity’s conformance to the spirit and purpose of the standards. 3. Perceive possibilities and provide ideas and counsel to the CAE and team of workers for enhancing their overall performance and that of the IA activity, elevating the fee brought to management and the audit committee. Thru its audits and consulting work, the IA activity will enhance the image, perceptions, and credibility of the group inside the organization.

Quality implication for the health care organizations

During the last period, a selection of techniques for procedure development from manufacturing and service operations have been switched to healthcare. These strategies consist of lean thinking, which seeks to take away activities or procedure steps that don't add value to clients, the principle of constraints, which seeks to eliminate bottlenecks in processes and 6 sigma, which aims to lessen variation and create free of error services.

We find that these industrial techniques, primarily based on a few years of improvement knowledge in different sectors, could make a considerable contribution to value and quality improvement in healthcare. However, those strategies need to be translated for clinical surroundings. This consists of providing the techniques in a language that clinical and managerial leaders can relate to, providing precise clinical examples and case studies and developing clinical champions for the application of those strategies. As those technique improvement strategies turn out to be more common in healthcare and their benefits are proven, they're a contribution to a new perspective amongst healthcare leaders about wherein the real issues are in the system and how to systematically enhance care.

Adopted measures to prevent service and care related problems (related to quality implications)?

In the following is the sum of what interviewees have stated:

Efforts to improve quality need to be measured to demonstrate “whether improvement efforts (1) lead to change in the primary end point in the desired direction, (2) contribute to unintended results in different parts of the system, and (3) require additional efforts to bring a process back into acceptable ranges”. The rationale for measuring quality improvement is the belief that good performance reflects good-quality practice, and that comparing performance among providers and organizations will encourage better performance. In the past few years, there has been a surge in measuring and reporting the performance of health care systems and processes. While public reporting of quality performance can be used to identify areas needing improvement and ascribe national, State, or other level of benchmarks, some providers have been sensitive to comparative performance data being published. Another audience for public reporting, consumers, has had problems interpreting the data in reports and has consequently not used the reports to the extent hoped to make informed decisions for higher-quality care.

Internal communication with staff and patients

The internal communication with staff and patients is divided into the following in the ascendant order:

• Committees with employees and staff

• Community Activities

• Internal Events

• HIS system

• General meeting with employees

Question 11 External communication evaluation

1. The external communication evaluation is based totally on the bond among medical doctors and hospitals.

2. Create policies for engagement.

3. Expand metrics. Center meetings around patient care.

4. Begin with small wins first.

5. Celebrate and share successes.

• The content analysis

Content analysis is a research method for studying documents and communication artifacts, which might be texts of various formats, pictures, audio or video. Social scientists use content analysis to examine patterns in communication in a replicable and systematic manner. One of the key advantages of using content analysis to analyses social phenomena is its non-invasive nature, in contrast to simulating social experiences or collecting survey answers.

Practices and philosophies of content analysis vary between academic disciplines. They all involve systematic reading or observation of texts or artifacts which are assigned labels (sometimes called codes) to indicate the presence of interesting, meaningful pieces of content. By systematically labeling the content of a set of texts, researchers can analyze patterns of content quantitatively using statistical methods or use qualitative methods to analyze meanings of content within texts (Hodder, 1994; Tiplado, 2014).

Computers are increasingly used in content analysis to automate the labeling (or coding) of documents. Simple computational techniques can provide descriptive data such as word frequencies and document lengths. Machine learning classifiers can greatly increase the number of texts that can be labeled, but the scientific utility of doing so is a matter of debate.

General accreditation programs appear to improve the structure and process of care. Randomization of this important trial controlled for important factors known to affect a hospital's ability to comply with and achieve accreditation standards for indicators such as hospital size, staffing levels, staff qualifications and budget levels. A positive impact of general accreditation programs on different specific clinical outcomes, including the management of AMI, trauma, ambulatory surgical care, infection control and pain management. The interviewee indicated that a significant positive impact of subspecialty accreditation programs in improving clinical outcomes in different subspecialties, including sleep medicine, chest pain management and trauma management. General accreditation programs of health organizations and accreditation of subspecialties should be encouraged and supported to improve the quality of healthcare services. One of the most important barriers to the implementation of accreditation programs is the skepticism of healthcare professionals in general and physicians in particular about the positive impact of accreditation programs on the quality of healthcare services. There is a need to educate healthcare professionals about the potential benefits of accreditation to resolve any skeptical attitude of healthcare professionals towards accreditation.

What are the data analyzed in content analysis?

The data analyzed in this thesis is all a result of the patterns discovered during the interviews with managers in different Lebanese hospitals. Sources of data could be from interviews, open-ended questions. This is done to develop pre-defined or interactive set of categories or concepts.

Reliability

To ensure the reliability of the study and from the researcher’s perspective, Not having a team of researchers does not preclude one from being able to assess intra-rater reliability (the researcher would need someone to help you with establishing inter-rater reliability). As Mackey and Gass (2005) explain, firstly, the researcher codes all the data. Then, after some lapse of time (few weeks) the researcher would need to re-code the data or some part of it. The scores achieved by the same researcher but at different points of time (hence, "intra-rater") can be compared through standard inter-rater reliability check procedures.

Content analysis is a data driven process, so the researcher’s data will determine the codes or labels. To ensure validity of you coding process, there are such procedures as "external audit" aka "peer checking" (Cresswell, 2012). Based on the feedback you will received from the reviewers (hence, "peer checking") you can make a judgement about the validity and, if needed, improve you coding approach.

Code generation and categorization

5. Conclusions and Recommendations

The researcher conducted a qualitative analysis technique over 60 hospital in Lebanon to investigate the “Evaluation of the need for External Quality Accreditation for Healthcare Organizations in Lebanon: Stakeholders Perspectives”. The researcher found that:

The results showed that the adopted measures to prevent service and care-related problems in the Accreditation System. According to the interviews “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve. The accreditation is not just about standard-setting: there are analytical, counseling and self-improvement dimensions to the process. There are parallel issues in evidence-based medicine, quality assurance and medical ethics, and the reduction of medical error is a key role of the accreditation process. Hospital accreditation is therefore one component in the maintenance of patient safety. However, there is limited and contested evidence supporting the effectiveness of accreditation programs.”

TQM is likewise imagined to place a greater emphasis on self-control, autonomy, and creativity, anticipating active cooperation from personnel as opposed to mere compliance with the employment agreement. 47.6% of the interviewees agreed that TQM positively affects the health center’s approaches. This consists of “continuous development, teamwork, training, top management dedication, and client focus. Non-stop improvement was the most considerable factor in explaining variance in implementing TQM concepts.”

The interviewees agreed that EQA and Organizational communication with employees is essential because it motivates the worker by promoting proper verbal exchange. Collaborating in an EQA scheme permits a laboratory to collect precious information.

The majority of the interviewees said that EQA and skills acquisition are interrelated in the case of skills choice. A few hospitals are using the skills acquisition system as a part of their general EQA system.

The following simple goals need to be accomplished in an external QA: 1. Determine the performance and effectiveness of the IA hobby in light of its charter, the expectancies of the board (generally represented by using an oversight body, along with an audit committee), executive management, and the CAE. Take into account the IA activity’s current needs and targets, in addition to the future direction and dreams of the company.

During the last period, a selection of techniques for procedure development from manufacturing and service operations have been switched to healthcare. These strategies consist of lean thinking, which seeks to take away activities or procedure steps that don't add value to clients, the principle of constraints, which seeks to eliminate bottlenecks in processes and 6 sigma, which aims to lessen variation and create free of error services.

Efforts to improve quality need to be measured to demonstrate “whether improvement efforts (1) lead to change in the primary end point in the desired direction, (2) contribute to unintended results in different parts of the system, and (3) require additional efforts to bring a process back into acceptable ranges”. The internal communication with staff and patients is divided into the following in the ascendant order: Committees with employees and staff; Community Activities; Internal Events; HIS system and General meeting with employees the majority of the interviewees stated that their hospitals adopt the ministry of health guidelines.