At present the virus is spreading in most countries and has not be contained so far, and Iran is ranked 15th amongst the countries with high prevalence of COVID-19 (Statistics on February 7rd, 2021). The Iranian health care system is struggling against this unprecedented crisis that opened the floor for new considerations in disease management. TUMS, as the largest and the oldest medical university in the country, leads confrontation against this disease, hence, managers and decision-makers therein provide medical services with a remarkable experience pooled during this crisis. Therefore, this research aimed at introducing an evident analysis of these experiences to assess the challenges, strengths and weaknesses, and draw lessons learned over this pandemic.
The high mortality rate in Iran at the peak time might be mainly attributed to the policies applied to control the epidemic and, of course, to treat and the failure in identifying all positive cases in the country (18).
Several factors including the policies adopted to control the epidemic, the system for detecting the positive cases at the community level, the ratio of hospital admissions to facilities such as ICU beds, ventilators, the variation in age and vulnerable groups, and the mortality rate in the country all need to be scrutinized and analyzed and the subsequent evidence effectively is tapped into for controlling the epidemic.
Most of the interviewees mentioned the challenge of Surprise and unpreparedness for the epidemic as the key managerial challenge. The deficiency in PPE and the less initial personal precautions, and paucity of medical and diagnostic equipment at hospitals in the early days of the crisis rendered this claim evident. In their correspondence with the chancellor of the national advisory committee on COVID-19 epidemic management, managers of the Iranian Health Insurance Organization have suggested to make use of the experience of other countries like China, England, Italy, and Spain in implementation of lockdown, and raising the awareness in the society on how to deal with the disease; “After the N1H1 flu epidemic, there was an evidence that measures should have been taken to strengthen the health care system and develop appropriate policies and procedures to deal with it, however, the decisions were not effective after the emergence of corona epidemic, or at least, they were not able to contain the virus transmission " (18). Considering the experience of China and some European countries shows that there was a need for serious measures and more preparations in Iran prior to the outbreak (19). The WHO has stated that the first window of opportunity to deal with the epidemic was supposed to be 1–2 months ahead to the epidemic in the country, whilst, many countries have missed this opportunity (20).
In time of corona crisis, managers had to make prompt decisions in the organization such as changes in the way of services provision, staff rotation, costs increase, etc., and this in turn led to staff resistance to these changes. One of the most influential ways for managers to mitigate this challenge is care the staff various needs and address the gap with them. Managers in critical situations ought to devote their leadership style to contain stress and concerns. As a rule of thumb, staff cooperate more when they are on a common ground with their superiors, in the same situation, and easily to reach and communicate.
Participants in this study stated that the crisis management courses they have enrolled in, and the knowledge they received were very effective in their successful control of the situation. Furthermore, self-management for the managers comes as a pre-requisite to their capability in managing the crisis. Patience, readiness to criticism, and openness to discussion are the most important personality traits and communication skills necessary for managers.
Furthermore, media acted on appreciating the sacrifices of medical staff and boosting their morale, and has greatly reduced the staff resistance to accepting corona patients. Using these strategies is one of the strengths of hospital managers affiliated with TUMS. The findings of this study indicate that the interdepartmental coordination and the harmony between managers and staff, and effective teamwork provided a concrete foundation for better management of this epidemic. These results were consistent with some previous experiences in other countries (17) (21).
Half of the interviewees stated that one of the managerial strengths is the support the staff receive and the empathy with the senior hospital managers. In such situation where employees struggle with the fear of being exposed to an unknown virus, and which coerced a group of them to leave their jobs accordingly, managers need to exert a great effort to uphold the morale of their staff. Several researches on human sciences demonstrated that a manager can increase performance and productivity in the organization, and enhance job motivation and satisfaction of employees and reduce stress among them by establishing proper communication and paying attention to their emotions (22).
One of the strengths of the Iranian health care system is the committed, skillful and experienced retired clinicians in all medical specialties. The public universities of medical sciences in Iran include thousands of specialists, physicians, and nurses, and many were significantly involved in preparing laboratories and health care centers in response to the pandemic (12).
Lack of facilities and equipment was the most influential structural weakness in the university hospitals. Most of the interviewees in this study believed that facilities such as convenient places for quarantine, as well as the equipment they need, such as ventilators, were not adequately provided. The latest reports from state officials said that these deficiencies are in its way to be addressed, yet, nothing has changed (24). A study conducted in India outlined the measures executed to manage this epidemic and prevent deficiencies: “Implementation of policies in line with the Indian standards depends on the availability of resources for ICUs as well as other departments, publishing guidelines on the rational use of medical resources during epidemics throughout hospitals and care centers for the various departments involved in executing policies” (21). The WHO has also recommended countries affected by the epidemic to take preventive steps against the virus spread including: readiness of health service centers, laboratories and health care providers with adequate protection equipment and upgrading resource management system (25).
Delay in diagnosis of patients was mentioned by the interviewees as the most clinical-diagnostic weakness. This problem can be partly due to not only the few information on the virus profile, but also the relatively long time required to get the results of PCR diagnostic test. Asymptomatic patients were admitted to the wards and were diagnosed with COVID-19 within a few days. Before the outbreak, training sessions were enough to improve the scientific knowledge of the medical staff, conversely, all groups should be enrolled in updated and special scientific webinars or effective preventive and treatment methods.
Having a capable advisory team and holding regular meetings for crisis committee were crucial to reducing the risk of decisions made. The results of recent decisions were reviewed regularly and the programs were amended or upgraded as needed. The flexibility of programs and the gradual response to challenges were appropriate solutions for similar situations. Also, the importance of preventive precautions these days and not attending gatherings, and the best utilization of virtual activities, were efficient measures in preventing the virus spread. Moreover, numerous virtual meetings and webinars to share expertise were regularly undertaken as fundamental measures.
One of the managerial weaknesses observed in this crisis was the imbalance in the provision and distribution of medical services across the country. Despite the importance of prevention in this epidemic, the preventive policies adopted were very weak (14). For instance, there was no quarantine nor severe traffic restrictions in the urban places in the first weeks of the outbreak, even though, this was one of the lessons drawn from the Chinese experience (19).
The level of delegation in decision-making was relatively high, and the poor centralized management in hospitals and colleges was recognized. These issues can be attributed to poor knowledge and management skills among officials. This indicates the necessity to employ graduates from management disciplines or carry out training courses on management for the current officials and policymakers. Managers participating in this study acknowledged that the crisis management courses were fruitful.
During the outbreak, many researchers tried to investigate the efficacy of new or traditional therapies for corona. To prohibit violation of patients’ rights, all researches must be ethically approved before being conducted. For that, an online system has been set up to monitor violations in these studies, thereby, infringements, if happened, should be reported by hospital staff and patients as well.
Another important challenge in research was the lack of electronic collection of patients’ data. The Iranian health care system was expected to detect the first cases more quickly preceding the death of the first positive case. In other articles, a major challenge appeared early in the epidemic in Iran was the data mismanagement, even though, there are several reporting systems in some provinces (17).
One of the limitations in this research was the generalizability of the results to all hospitals in the country. Furthermore, the study results have been drawn from the interviewees’ experiences in the early stages of the outbreak, and this might be emotionally influential or some potential updates might be recently arisen.