Journal of Modern Medical

Introduction
In Wuhan, China in 2019, after people had pneumonia without a clear cause and the existing vaccines and treatments were not effective, a new type of coronavirus was identified, which was later named COVID-19. The high volume of visitors to medical centers during the COVID-19 pandemic has affected the evaluation index of hospitals. Various indicators are used to measure performance of hospitals, but there is no standard procedure in this time. The usual procedure is that several components in relation to the performance are first selected; then, each component is measured with a question objectively or subjectively. One of the new areas of ethics is that it tries to respond to the ethical issues of various professions and set special principles for them. Considering that the pandemic has directly targeted the front line of hospitals (medical staff), it can obviously affect the performance of hospitals. Most studies evaluate performance and efficiency based on historical data related to the organization. These studies do not focus on goals. In this study, we focus on intangible goals and professional ethics in medicine.
Methods
The study population consists of physicians and managers in different departments of 37 hospitals in Shiraz, Iran. Using the Morgan’s table, 378 were selected as samples. Of these, 315 returned their questionnaires; 15 were removed due to being incomplete and finally the data of 300 questionnaires were analyzed. A fuzzy model was presented in following steps:
Causal relationships and interactions using the DEMATEL method were determined. The combined performance analysis of medical and professional ethics across the DEA network was performed for sequential ranking among hospitals;
Since BSC is based on causal relationships, DEMATEL was used in the next step to determine these relationships. A DEA model was developed to determine the efficiency of hospitals based on medical/professional ethics Hospitals were ranked by DEA and BSC methods.
3. Results
In this study, all the inputs and outputs for each medical/professional ethics indicators were set in one of the four aspects of BSC approach; the three perspectives of “learning and growth”, “customer”, and “financial” were selected as inputs and the four perspectives of “learning and growth”, “internal process”, “customer”, and “financial” as outputs. The BSC system was integrated with DEA models, resulting in a powerful measurement tool.
The results showed that DMUs (hospitals) 1, 3, 5, 8, 12, 13, 17, 21, 22, 23, 24, 25, 27, 28, 29, 30, 31, 32, 33, 35, 36 and 37 were efficient, while other DMUs were inefficient. In evaluating the overall performance of hospitals, those with an overall performance of 1-100% were selected as efficient (Table 1).




Discussion
The efficiency score in learning and growth perspective was lower than in other perspectives, and all hospitals were efficient in terms of customer perspective. This shows that managers of hospitals have less emphasis on learning and growth and pay more attention to customers. This indicates the relatively poor performance of hospitals managers during the pandemic with respect to this indicator. Poor performance in learning and growth perspective leads to a decrease in productivity in the next stages, which can be improved by holding in-service training courses for physicians. The main focus of this study was on the evaluation of medical/professional ethics. The proposed model can be used to rank the efficient supply of health care by hospitals in order to identify their efficiency.
It is recommended that during the COVID-19 outbreak when the perspectives of learning & growth and internal process are less considered, managers should design in-service training programs, conduct regular payments such as merit pay, and develop guidelines for fighting against the pandemic so that the hospitals be more agile when the number of patients is high and have a better evaluation of their performance. One of the strengths of this study was the design of a model that had the lowest error rate and included all the qualitative aspects of medical and professional ethics. It also revealed which hospitals had more challenges during the pandemic with affected evaluation process.

Ethical Considerations
Compliance with ethical guidelines
The present study was approved by the medical ethics committee of Shiraz branch of Islamic Azad University (Code:  IR.IAU.SHIRAZ.REC.1400.022) has arrived.

Funding
This article is extracted from the thesis of Mehdi Golrizkhatami (first author) and has no financial sponsor

Authors' contributions
Conceptualization: Mehdi Golrizkhatami: Method: Morteza Shafiee; Review: Mehdi Golrizkhatami-Morteza Shafiee; Original draft: Mehdi Golrizkhatami; Review and display: Amir Kazemi; Sources, Supervision: All authors.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We would like to thank all the medical staff of Shiraz city hospitals and Shiraz branch of Islamic Azad University.


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