What is the mind map of the hospital's future changes in a developing country like Iran? A qualitative study

What is the mind map of the hospital's future changes in a developing country like Iran? 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A qualitative study Ali Masoud, Reza Dehnavieh, Vahid Yazdi-Feyzabadi, Atousa Poursheikhali, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2004067/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Jul, 2023 Read the published version in BMC Health Services Research → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Hospitals have a vital role in the future of health systems but will change. Identifying the potential aspects of change helps managers have a proactive approach in dealing with them, make use of the opportunities, and avoid threats. This study presents a mind map of future changes in Iranian hospitals to develop a base for further related studies or prepare evidence for interventions and future-related decisions. Methods: This study is a qualitative-exploratory one, conducted in two phases. In the first phase, in-depth and semi-structured interviews were conducted to identify the future changes of the hospitals over a 15-year time horizon. The interviews were analyzed using the content analysis method and MAXQDA 2018 software and holding two expert panels to develop the mind map using the 2016 Visio software. Results: In the first phase, 33 interviews led to 144 change patterns. In the second phase, a mind map of changes was drawn according to experts' opinions with ten categories: structure and role, knowledge management and research, service delivery, health forces, political and legal, economic, demographic and disease, technological, and values and philosophy, and environmental. Conclusions: Many changes affecting hospitals rooted in the past continue to the future, but the point is the increasing intensity and speed of changes. Health care systems need a systematic approach to monitoring the environment to be updated, agile and proactive. These monitoring systems are essential in providing evidence for Macro-level decision makers. Mind map future changes hospital Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Background Hospitals are one of the main components of the health system and play an essential role in caring for patients and completing other system functions. They support primary health care providers and the training of health care professionals and researchers. Achieving universal health coverage (UHC) and sustainable development goals requires the commitment of all layers of the health system, including hospitals (Huntington, 2015 ). Driving forces can challenge the hospitals in their strategic and clinical processes while increasing the uncertainty of the future (Erwin, 2019). Trends like rising costs, epidemiological transmission, antimicrobial resistance, the incidence of chronic diseases, aging, urbanization, increasing demand, social and cultural changes, changes in economic conditions and the health market, and competition for attraction and retention of talents and new organizational structure models affect the future of hospitals (Walsh, 2019. Mossialos, 1999 . O'Neill, 2016. Santiago, 2019. Khalifa, 2017. Kalhor, 2016). We are encountering emerging health-related technologies in medical equipment, surgical techniques, various drugs, biological products, and information systems (Lin X, 2021). Health literacy has become more highlighted and is an important public health goal for the 21st century (Nutbeam, 2000 ). Mixed markets are emerging where public and private hospitals compete in attracting public funds and responding to needs (Levaggi, 2020 ). In the past years, attention has been paid to health service providers such as hospitals through collaborative networks (Mascia, 2015). The growth of medical tourism and patients traveling to other countries to receive health services has created new forms of health services. It is changing hospitals' architecture, design, management, and organization (Bochaton, 2008). The mentioned cases are examples of hospital changes regarding the future. This institution's future has many scopes, dispersion, and changes. It will be vital for managers and decision-makers of the health system to identify and monitor the upcoming changes to manage them proactively. In the past years, Iranian hospitals have undergone many changes, including financial and structural reforms, decentralization, changing payment mechanisms, outsourcing, and increasing the participation of the public and private sectors (Jafari, 2018). Along with the changes, the hospitals have also faced challenges like the increased cost more than three times in recent years (Arab-Zozani, 2020). They still face many other challenges regarding accountability, efficiency, quality, and safety (Jafari, 2018). This study tries to identify the future drivers of change that affect hospitals via a systemic approach and mapping the elements as a mind map. Methods This study is a qualitative one with an exploratory approach trying to identify the future drivers of hospitals in Iran consisting of two main phases. The first phase was collecting qualitative data and determining the coming changes in hospitals, and the second was mapping the elements as a mind map. The stages and their steps are presented as follows: Collecting qualitative data and determining the future changes in hospitals To collect the future changes in hospitals, open and semi-structured interviews were conducted. All the participants were selected using a purposeful and snowball approach. In determining the participants, the main criterion was to cover the health system sub-systems as much as possible. The following criterion was having more than five years of related work experience or being active in the research or education in the health system's future. At the beginning of this phase, in-depth interviews were conducted with the purposeful sampling approach. The main question of the in-depth interview was: What are the main aspects of hospital changes in the next 15 years? The reason for choosing a 15-year time horizon is that numerous studies have worked on determining the future changes in the health system and hospitals; they chose the time range between 12 and 20 years for their study and pointed out that the horizon is suitable for examining future changes (Fellows, 2016. Adamopoulos, 2013. Braithwaite, 2018). After content analyzing the interviews, the following interviews were semi-structured. All interviews were conducted between April and July 2021. The duration of the interviews varied from 22 to 80 minutes. At the beginning of all the interviews, the participants were aware of the purpose of the study, and informed consent was obtained from them . The transcription of the recorded interviews was analyzed with a content analysis approach and using MAXQDA 2018. The content analysis method was used as suggested by Erlingsson and his colleagues (Erlingsson, 2017). Developing the mind map A mind map model helps provide efficient, accurate, and creative solutions. This tool can expand thinking in all fields of education, work, and human life (Chen, 2008) by visualizing insights related to the subject of study and developing relationships between ideas. Concepts, keywords, colors, and images can be used to prepare a mind map while the vital concept is placed in the center, and other concepts branch from it (Buzan, 2005. Buzan, 2018). A mind map is rooted in cognitive structures, and understanding this map is easier for the audience than written texts (Harkirat, 2011). The purpose of the second phase was to categorize the ideas and draw a cognitive map of the future changes in the hospitals. Two expert panels were held in October 2021, and the second 11 days apart virtually with the sky room platform. The participants in this phase were selected purposefully among the first phase participants based on the inclusion and exclusion criteria. The first panel presented the changes resulting from phase one to experts. The experts categorized the changes and labeled them by the facilitator’s guide. With permission, note-taking was done during the meeting by two researchers. After finishing the first panel, the research team drew a mental map of the hospital’s future changes using Visio 2016. After mapping the mind map, the second meeting of the expert panel was held. The drawn map was presented during the second session, and the participants issued potential enhancement or edition points. Finally, the amendments were applied according to the expert’s opinion. Results To determine the future changes affecting the hospitals, 33 people were interviewed in the first phase. The characteristics of the participants in this phase are presented in table number one (table 1). Table 1. Characteristics of participants in phase one Organization Role/task Number Ministry of Health and Medical Education (MOHME) Specialists of Research and Technology Vice-Chancellor Specialists of the Vice-Chancellor of Education Specialists of the Vice-Chancellor of Treatment Specialists of the Deputy Food and Drug Administration Specialists of the vice president of development and management and planning 7 health insurance (HI) Specialists of the Social Security Health Insurance Organization Specialists of Iran Health Insurance Organization 5 Health care Provider HP General practitioner specialist Nurse 5 Hospital Management HM Hospital managers Hospital supervisors Officials of quality improvement units 7 Researchers and faculty members RFM Researchers in the field of health economics, health service management, health technology assessment, and futures studies in health 9 By content analyzing the interviews in phase one, 144 elements of change were identified. Some of them are mentioned as follows. Participants stated that hospitals would become smaller but more specialized in the future. "... hospitals will only focus on patients for whom the other health system providers will not have the necessary facilities and expertise, and patients with complex conditions will be referred to them from other levels, and simpler cases will also be at other levels. To be treated ..." (MoH). Hospitals will have an active, patient-oriented, and user-friendly social role." Providing services will not be limited to hospitals. Hospital teams in the community will actively promote the lifestyle and treatment of patients in their homes..” (HP). "Due to factors such as the growth of technology and information; The quality and safety of services will increase, the preferences of patients will be taken into account in the design of spaces, processes, and services of hospitals ..." (HM) . There will be an increase in the patient’s and health force’s mobility. "Due to megatrends such as globalization or trends of increasing immigration and urbanization, we will see patients and health workers with different cultures from different cities and countries every day..." (RFM) . A change in the characteristics of the health workforce will occur. " With the arrival of the millennial generation, we will see rapid and large changes in the expectations of employees from work environments. The retirement age will increase to compensate for the lack of workforce and skills " ( MoH). National and international cooperation and interactions of hospitals with each other and related stakeholders will increase. "...health tourism will flourish..., national and international standards and institutions supervising the activities of hospitals will increase, and hospitals will form a network with each other and use each other's resources and experiences" (RFM). "As the role of hospitals in improving the health of communities increases, they will need to cooperate with different stakeholders because they can not achieve this goal lonely" (HM) . Changes in developed countries will happen faster than in developing countries. Also, the rate of change has increased compared to the past ." In my opinion, due to trends such as globalization and international communication, several changes are common between developed and developing countries, such as technologies; the only difference is that usually, These changes in those [developed] countries have either already happened or their speed and intensity are more significant than in developing countries..., another point that comes to my mind is the speed of changes. We constantly change in the workforce. Or we had the expectations of the patients, but the only thing that has happened now is that due to the growth of technologies such as the media and the Internet, their speed has now increased ..." (RFM). Another point that can be extracted from this interview is that some changes will facilitate and accelerate other changes. For example, developing health monitoring technologies will enable the development of home care services for patients . In the future, we will see changes in the composition and pattern of diseases . "Clearly, due to the increase in life expectancy and the population aging, it can be predicted that the burden of chronic diseases will increase, even in my opinion, the state of multiple diseases and physical and mental diseases will increase together..." (RFM). "Climate changes, drought or global warming and even water and food insecurity that we are witnessing now, can potentially change the patterns of chronic and infectious diseases" (RFM). "The experience of Covid-19 also showed that the threats of emerging and re-emerging infectious diseases can always exist, so future hospitals should not neglect these issues" (MoH) . Environmental scanning units will be activated in future hospitals. "Hospital administrators will be aware of the importance of political, social, and economic changes in the hospital environment and will monitor them. In my opinion, future hospitals will establish active environmental monitoring units" (HM). The role of the private sector and attention to financial efficiency will increase due to the lack of resources and the increase in technological costs . "Hospitals will increase partnerships with private sectors and non-governmental organizations to attract more resources..., strategic purchasing will be done more carefully" (HI). The growth of technology will move forward faster and affect all sectors of the healthcare system . "In my opinion, using cryptocurrencies and technologies such as blockchain will increase hospitals' financial and information transfers. It would help if you considered that with the growth of big data and the increase in its use, blockchain could be used to maintain this information in the health system" (HI). "In the past years, we consider a significant growth in health technologies, wearable health sensors that help patients control health parameters are one of them. I hope hospital information systems will use this information in the future" (HP). "The development of information analysis methods such as cloud computing can greatly help health systems analyze big data" (RFM). A change in norms will happen . "Associations supporting patients' rights will become more and more active. Due to the growth of social networks, patients will be able to form a network with each other and express their expectations loudly" (RFM). The problems of life and the rush and stress that people have now will cause them mental issues; in my opinion, attention to spiritual health will also increase (HP) . In the second phase, 12 experts were selected among the participants of the first phase. Table two shows the participants' characteristics in the panel of experts (table number 2). Table 2. Details of participants in the expert panel Organization Role/Tas Number Ministry of Health and Medical Education(MOHME) Vice President of Development and Management and Planning 1 health insurance (HI) expert of Iran Health Insurance Organization 2 Health care Provider HP General practitioner 1 Hospital Management HM Hospital managers 2 Researchers and faculty members RFM Health services management, health economics, health technology assessment, and futures studies in health 7 To prepare the mind map framework, the experts categorized the future changes into ten main categories as follows: Structure and role Management of knowledge and research Service delivery Health forces Political and legal issues Economic Population and disease Technological issues Values and Philosophy Environmental issues And in the next step, the concepts' cognitive map was drawn with experts' participation and insights (Figure 1). Discussion The speed of changes in the 21st century is faster than in previous years (Rechel, 2009). Health care is not excluded from these changes and is one of the most complex and growing industries worldwide (Preker, 2016). Hospitals are also one of the critical components of health systems. Hospital services constitute about 50% of the total health costs (Levaggi, 2020 ). It is necessary to pay attention to hospitals to improve the overall performance of the health system (Ehler, 2018). The present study showed that the future of hospitals is affected by many factors interacting inside and outside the hospital’s scope and health system. Structure and role In the future, hospitals will become specialized and small places where services will not be provided by other health service providers and will be exclusive to them. Less technical and palliative services will be transferred to primary care providers, nursing centers, or patients' homes. Besides, integrating specialized services in hospitals will keep them in the servicedelivery line to respond to society's needs. Their number will be reduced, or they will not be constructed without a needs assessment. Barber also points out in his study that the speed of establishing hospitals will be slower in the future, and they will probably face stricter controls on construction and size (Barber, 2014). Also, the congestion in hospitals will decrease over time. However, diseases and more complex treatment methods will remain in the future hospital, making them more specialized and smaller (Zimlichman, 2019). Future hospitals will network with other health care providers to share knowledge, experiences, and resources. They will collaborate to identify and respond to community health needs. The network structure allows for economies, proper consumption of resources, development of innovative capabilities of hospitals, reduction of the negative aspect of competition between hospitals, creation of a sustainable market-based health system, and ensuring effective care of patients (Illés, 2016. Mascia, 2015). The map of the related structural and role elements is presented in Fig. 2 . Knowledge and research Future hospitals will play a more active role in knowledge production by using different research methods and knowledge translation. These hospitals will provide the context of the activities of researchers and facilitate start-ups. Attention to social medicine and educational issues will be strengthened. Health environmental monitoring units will be established to identify and manage existing and future changes and trends. Due to rapid growth and progress in the health system, the field of "health innovation" will be supported, and it examines and monitors health developments and innovations at the global level to increase confidence and reduce risks (Dawe, 2015). The knowledge and research related elements of the future changes is presented in Fig. 3 as follows. Service delivery Hospitals will continue their service delivery through multidisciplinary teams and teamwork-based. Patient-centered and providing teamwork services will be necessary to meet the needs of the future (Mokhtar, 2017 ). Absolute coordination with other providers is another point. Schurr quotes Thomas Bodenheimer " Patients with multiple chronic diseases are likely to see about 16 doctors a year. In the meantime, treatments and diagnostic processes may be repeated by doctors, which is dangerous and also costly for patients " (Schurr, 2015 ). One example of lacking the integrated model of services delivery is patient mortality, about one-third of deaths in the United States are due to acute myocardial infarction in the post-hospital discharge phase (Cherlin, 2013). These problems need even more coordination between hospitals and health service providers in the future to ensure the population’s health and prevent and reduce errors. The map of the service delivery section is presented in Fig. 4 . Health forces In the future, the hospital staff will be of new generations with different characteristics than past ones. Generation Z was born after 1995; they grew up in the internet world and are used to technology. As mapped in Fig. 5 , their characteristics are self-reliance, freedom, high use of technology, and desire for speed. They are primarily online and spend little time in the real world, reinforced by metaverse. This generation wants a balance between work and personal life, friendly relationships in the workplace, support for personal development, and an opportunity to flourish and prove themselves (Bieleń, 2020 ). Managers should make work environments attractive to retain and attract them. Flexible working hours and territories are among these factors. One of the critical issues predicted for the future health system workforce is the need for interdisciplinary competencies and the ability to work in collaborative teams. In recent years, there has been increasing pressure in higher education to train graduates in the health system with the capabilities to work effectively in collaborative and interdisciplinary teams to solve critical issues. For this purpose, the approach to interprofessional education has been developed (Brewer, 2018 ). More emphasis will be placed on increasing health literacy among hospital staff. It is assumed that high health literacy among health workers will improve patients' health literacy. There is a positive relationship between health literacy and the health status of the population and a negative association with health inequalities (Budhathoki, 2019). Due to its importance, hospital and university managers must take interventions regarding improving the health literacy of the future forces of the health system. Political and Legal Rechel states that are regulating hospitals and their services are not only a technical or managerial issue but a political decision to a great extent (Rechel, 2009). Various political and legal trends will affect the future of hospitals. In the present study, the experts pointed out that locating the Middle East and the continuous conflicts and terrorism in this region, the threats caused by these factors should always be considered by the future planners of hospitals. Political communication and exchanges between countries have grown in recent years and have expanded the phenomenon of globalization. Globalization is a multi-dimensional and complex process that is also related to health and can potentially increase access to health care. The openness of import and export will increase competition among companies and affect working conditions and wages, indirectly affecting society’s health. Globalization increases the possibility of spreading infectious diseases such as COVID-19, but can improve the quality of health in low-income countries on the other side (Yang, 2021 ). In today's world, governments try to communicate with each other and use their potential for growth and development. Globalization provides an opportunity for the health systems of mainly developing countries to learn from best practices worldwide or to attract resources for their growth by establishing active health diplomacy. The political and legal elements of change is presented in Fig. 6 . Economical As also presented in Fig. 7 , Cancer mortality is higher in individuals with no insurance (Nolan, 2022) showing the importance of insurance for chronic diseases on the other side society's demand for insurance coverage for chronic and palliative diseases will increase with the rise in the population’s average age and elderly-related diseases. Marketing skills will be another key tool for success in health systems and especially hospitals in the future. Service research, service design, and strategic aspects of marketing are vital factors in designing and providing future health services (Sidney, 2018). Managers and decision-makers need to empower future hospitals and their workforce to gain an advantage in this regard. Population and disease The risk of emerging and spreading infectious diseases is rapidly increasing due to global environmental changes and increased migration (Lee, 2017 ). The experience of the Covid-19 spread shows that emerging diseases could turn into a pandemic and affect all aspects of life, such as social, economic, and health. It would be simplified to plan and design future hospitals merely based on chronic or elderly-related diseases. Covid-19 had many lessons in this regard and considered the flexibility of hospitals for potential upcoming challenges. In addition to considering infectious diseases, it is a fact that the world's population is aging due to declining fertility rates and increased life expectancy (Uhlenberg, 2013 ). According to the World Health Organization, about 40 million people need palliative care every year. About 78% live in low-income and middle-income countries, and only about 14% of people who need palliative and end-stage care receive it. In the past decades, treatments' complexity has increased in hospitals' end-of-life care (De Roodenbeke, 2015 ). In the future, special attention will be paid to hospitals to provide services to chronic patients and palliative care. It will be necessary for hospitals to form a network with informal providers inside patients' homes and care centers outside the hospital and support them technically. Antimicrobial resistance is another challenge for the future of global health. This challenge can potentially damage billions of dollars annually to the global economy and treat the lives of 10 million people by 2050 (O'Neill, 2016). It is necessary to constantly remind hospitals of these issues and use their scientific potential, equipment, and staff to proactively approach these future-related matters. The demographic and diseases-related elements are presented in Fig. 8 . Technology One of the emphasized future changes is technology development, advancing faster than ever for hospitals. It has been mentioned that digital health is one of the main drivers of any change in the future of health systems (Herrmann, 2018). Many advances in wearable sensors, mobile health technologies, information technology, telemedicine, and network systems have provided the way to provide health services and the possibility of remote monitoring of health parameters, especially for chronic patients, which results in effective disease management—and improving the patient's quality of life (Rajagopalan, 2019 . Vespa et al. 2010). Intelligent and comprehensive health systems use technologies through which patients can self-manage their health symptoms. These technologies will improve treatment decisions at the right time and medication adherence (Rajagopalan, 2019 ). With new, more effective, and personalized medicine, patients are living longer, and many previously incurable diseases are now well managed as chronic diseases (Schurr, 2015 ). Along with the many advantages of technology, it should be noted that it can significantly increase health costs. It is also important to note that these technologies do not always lead to improved clinical outcomes. Safety is also one of the issues of technology (Sampietro-Colom, 2016). In future hospitals, it will be necessary to have a systematic, transparent, and impartial evaluation of health technology. The technological-related elements of the map are presented in Fig. 9 . Values ​​and Philosophy Changes in concepts, principles, and values ​​of different stakeholders of hospitals have started and will continue. Patients are transitioning from passive recipients of services to active ones. Their expectations for value, satisfaction, and experience are also increasing (Sidney, 2018). Laurent Gille and colleagues acknowledge that determinants of health care demand will change. They believe that in the medium and long term, the emphasis will no longer be on the right to have an effective treatment but on the duty of being healthy, showing a shift from "right" to "duty" (Gille, 2014 ). In the future, hospitals will make more use of patients' participation in treatment processes. One option would be to change the name of the hospitals from "Hospital" to "Health Homes." Empowering and improving patients' living conditions will be one of the missions of hospitals, which will improve health outcomes and reduce the workload of hospitals. Ahn also points out that empowering people with chronic diseases to manage their conditions will improve health and lower costs (Ahn et al. 2013 ). The values and philosophy-related elements are presented in Fig. 10 . Environmental Pollution of air, water, and soil has increased dramatically due to industrial reasons and the use of vehicles in the past years and is predicted to increase more if there is no intervention in this regard. It is also expected that the most significant increase in pollution will be seen in the cities of low and middle-income countries and rapidly industrializing countries (Lelieveld, 2015). Air pollution in developing countries, like Iran, is also a significant health challenge (Mojarrad, 2020). Unfortunately, Iran ranks fifth in the world in terms of plastic consumption, which is high. Nearly half a million tons of plastic are used in Iran annually, and about 5000 tons of plastic are produced as waste daily. Pollution caused by plastic particles can have many health risks (Khayamabshi, 2016 ). All forms of pollution were the reason for about 9 million premature deaths in 2015, or 16% of all deaths worldwide. It is also estimated that about 268 million disability-adjusted life-years (DALYs) occur due to pollution (Abdulmuhsin, 2016). Climate change is another challenge that has intensified in the past decades. This challenge affects the health of communities through climate change, the spread of infectious diseases, changes in the workforce's capacity, and the effect on food security (Di Napoli, 2022). Unfortunately, Middle East countries will experience the negative consequences of climate change more than other countries in the world (Sharafati, 2022). It is estimated that by the year 2100, the average temperature in most regions of Iran will increase by more than 4 degrees Celsius (Borna, 2011). Therefore, it seems that diseases related to pollution and climate change will plague future hospitals. More information of the environmental future changes are presented in Fig. 11 . Conclusions Many of the changes mentioned in this study started in the past and will continue in the future and the point is in the increasing intensity and speed of changes. The study scope was Iran as a developing country in a time horizon of 15 years. Also, the occurrence of one or more wild cards may affect the mentioned trends, but the absolute point is that the future of hospitals will have profound changes in terms of structural, political, and health forces; and it will be helpful for future studies to identify these wild cards and evaluate their effects on future changes. These changes have synergies and interactions that alternatives of their future status shape different scenarios and it is suggested to conduct studies in this regard. Another suggestion of the current study is to establish environmental monitoring units both at the macro level of the health system and in the hospitals to monitor changes for informed decision-making and planning. The main limitation of the current study was the outbreak of the Covid-19 disease at the time of the study, which caused problems in receiving interviews and holding expert panels, which the research team tried to solve by using virtual communication facilities. This study summarized and categorized the future changes in hospitals in the form of a mind map. Considering the advantages of the mind map, we hope that the future managers of the health system and hospitals will act with a more open vision and a future-thinking approach to plan for the future. According to Erwin's opinion, hospital managers need to ask themselves whether their current management approach is optimal or not (Erwin, 2019). Declarations Acknowledgment We are grateful to all participants who contributed to this study. Conflict of Interests The authors declare that they have no competing interests. Ethics Approval This work was done with ethical approval and consent to participate. 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Huntington, Dale, and Krishna Hort, eds. “Public Hospital Governance in the Asia Pacific Region — Drivers of Change.” Public Hospital Governance in Asia and the Pacific. World Health Organization, 2015. http://www.jstor.org/stable/resrep28456.3. O’Neill J. Tackling drug-resistant infections globally: final report and recommendations. London: Government of the United Kingdom; 2016. Mascia D, Angeli F, Di Vincenzo F. Effect of hospital referral networks on patient readmissions. Social Science & Medicine. 2015 May 1;132:113-21. Levaggi L, Levaggi R. Is there scope for mixed markets in the provision of hospital care?. Social Science & Medicine. 2020 Feb 1;247:112810. Erwin CO, Landry AY, Livingston AC, Dias A. Effective governance and hospital boards revisited: Reflections on 25 years of research. Medical Care Research and Review. 2019 Apr;76(2):131-66. Bochaton A, Lefebvre B. The rebirth of the hospital: Heterotopia and medical tourism in Asia. InAsia on tour 2008 Sep 24 (pp. 113-124). Routledge. World Bank. Iran, Islamic Rep. Washington, DC: The World Bank; 2022. https://data.worldbank.org/country/iran-islamic-rep. Accessed 30 July 2022. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Jul, 2023 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Major revision 15 Feb, 2023 Reviews received at journal 14 Oct, 2022 Reviewers agreed at journal 03 Oct, 2022 Reviewers agreed at journal 03 Oct, 2022 Reviewers invited by journal 30 Sep, 2022 Editor assigned by journal 30 Sep, 2022 Editor invited by journal 10 Sep, 2022 Submission checks completed at journal 10 Sep, 2022 First submitted to journal 27 Aug, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2004067","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":135655029,"identity":"14b823dd-dec3-4e91-8c11-bd8e2c79eda9","order_by":0,"name":"Ali Masoud","email":"","orcid":"","institution":"Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Masoud","suffix":""},{"id":135655030,"identity":"16db72ee-cc43-4f58-bf00-cfcfb2b47ff9","order_by":1,"name":"Reza 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future\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/5985441b96e4ad7580388bc8.png"},{"id":26422127,"identity":"166270e6-7532-4cbb-9edf-fbe95a1242e0","added_by":"auto","created_at":"2022-09-13 21:18:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":158329,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in structure and role\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/9e37721c118d79c860159543.png"},{"id":26422128,"identity":"fd9efa99-4471-4ad2-8e28-2650475a2e81","added_by":"auto","created_at":"2022-09-13 21:18:06","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":166784,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in knowledge and research\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/e5dbffdd9ef3bbe725505e55.png"},{"id":26423237,"identity":"332f5545-32f1-4f66-a9b0-942bce5e02a4","added_by":"auto","created_at":"2022-09-13 21:28:06","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":307141,"visible":true,"origin":"","legend":"\u003cp\u003eService delivery changes\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/c70c2675b75188b1caa81d34.png"},{"id":26422137,"identity":"d29ea7d9-6983-45ea-9f21-aa2943a9e7fb","added_by":"auto","created_at":"2022-09-13 21:18:06","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":355199,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in health forces\u003c/p\u003e","description":"","filename":"figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/27c6396ec5b950b829600c81.png"},{"id":26423438,"identity":"e543fab5-184b-487d-bd0b-9a8aed1817fb","added_by":"auto","created_at":"2022-09-13 21:33:06","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":231674,"visible":true,"origin":"","legend":"\u003cp\u003ePolitical and legal changes\u003c/p\u003e","description":"","filename":"figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/54ac9ccbb0a8770849d6dd1e.png"},{"id":26422959,"identity":"757bdcdb-f88d-4095-af3c-1a6cf0cfb1b7","added_by":"auto","created_at":"2022-09-13 21:23:06","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":334035,"visible":true,"origin":"","legend":"\u003cp\u003eEconomic changes\u003c/p\u003e","description":"","filename":"figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/9fca3bea237dea51b251d2e2.png"},{"id":26422965,"identity":"9f7dd5ea-465b-4ac9-bfb3-c1a9c3f404dc","added_by":"auto","created_at":"2022-09-13 21:23:06","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":347388,"visible":true,"origin":"","legend":"\u003cp\u003eDemographic changes and disease\u003c/p\u003e","description":"","filename":"figure8.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/fbb32ef35d8caf40217057d7.png"},{"id":26423236,"identity":"abd4a20c-4b72-4752-91bb-a69fd2367008","added_by":"auto","created_at":"2022-09-13 21:28:06","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":272357,"visible":true,"origin":"","legend":"\u003cp\u003eTechnological changes\u003c/p\u003e","description":"","filename":"figure9.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/336166482be971c43abe03c2.png"},{"id":26422131,"identity":"323910ca-f134-4aa7-ae9b-eaba34453588","added_by":"auto","created_at":"2022-09-13 21:18:06","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":285633,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in values and philosophy\u003c/p\u003e","description":"","filename":"figure10.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/951ccb01ca3c082a45530ca0.png"},{"id":26422962,"identity":"1bd5076b-d9f7-4462-be9b-5f7016792e02","added_by":"auto","created_at":"2022-09-13 21:23:06","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":144864,"visible":true,"origin":"","legend":"\u003cp\u003eEnvironmental changes\u003c/p\u003e","description":"","filename":"figure11.png","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/53565db924f34428f5f47734.png"},{"id":44734856,"identity":"5e8eac2c-b4a2-412e-acbd-c0f6b1dba0dc","added_by":"auto","created_at":"2023-10-16 22:21:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4034605,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2004067/v1/f614ec8e-3c9c-4386-ab86-cc3bc7fd4b36.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"What is the mind map of the hospital's future changes in a developing country like Iran? A qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eHospitals are one of the main components of the health system and play an essential role in caring for patients and completing other system functions. They support primary health care providers and the training of health care professionals and researchers. Achieving universal health coverage (UHC) and sustainable development goals requires the commitment of all layers of the health system, including hospitals (Huntington, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDriving forces can challenge the hospitals in their strategic and clinical processes while increasing the uncertainty of the future (Erwin, 2019). Trends like rising costs, epidemiological transmission, antimicrobial resistance, the incidence of chronic diseases, aging, urbanization, increasing demand, social and cultural changes, changes in economic conditions and the health market, and competition for attraction and retention of talents and new organizational structure models affect the future of hospitals (Walsh, 2019. Mossialos, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1999\u003c/span\u003e. O'Neill, 2016. Santiago, 2019. Khalifa, 2017. Kalhor, 2016). We are encountering emerging health-related technologies in medical equipment, surgical techniques, various drugs, biological products, and information systems (Lin X, 2021). Health literacy has become more highlighted and is an important public health goal for the 21st century (Nutbeam, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). Mixed markets are emerging where public and private hospitals compete in attracting public funds and responding to needs (Levaggi, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In the past years, attention has been paid to health service providers such as hospitals through collaborative networks (Mascia, 2015). The growth of medical tourism and patients traveling to other countries to receive health services has created new forms of health services. It is changing hospitals' architecture, design, management, and organization (Bochaton, 2008).\u003c/p\u003e \u003cp\u003eThe mentioned cases are examples of hospital changes regarding the future. This institution's future has many scopes, dispersion, and changes. It will be vital for managers and decision-makers of the health system to identify and monitor the upcoming changes to manage them proactively. In the past years, Iranian hospitals have undergone many changes, including financial and structural reforms, decentralization, changing payment mechanisms, outsourcing, and increasing the participation of the public and private sectors (Jafari, 2018).\u003c/p\u003e \u003cp\u003eAlong with the changes, the hospitals have also faced challenges like the increased cost more than three times in recent years (Arab-Zozani, 2020). They still face many other challenges regarding accountability, efficiency, quality, and safety (Jafari, 2018). This study tries to identify the future drivers of change that affect hospitals via a systemic approach and mapping the elements as a mind map.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is a qualitative one with an exploratory approach trying to identify the future drivers of hospitals in Iran consisting of two main phases. The first phase was collecting qualitative data and determining the coming changes in hospitals, and the second was mapping the elements as a mind map. The stages and their steps are presented as follows: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCollecting qualitative data and determining the future changes in hospitals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo collect the future changes in hospitals, open and semi-structured interviews were conducted. All the participants were selected using a purposeful and snowball approach. In determining the participants, the main criterion was to cover the health system sub-systems as much as possible. The following criterion was having more than five years of related work experience or being active in the research or education in the health system\u0026apos;s future.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the beginning of this phase, in-depth interviews were conducted with the purposeful sampling approach. The main question of the in-depth interview was: What are the main aspects of hospital changes in the next 15 years? The reason for choosing a 15-year time horizon is that numerous studies have worked on determining the future changes in the health system and hospitals; they chose the time range between 12 and 20 years for their study and pointed out that the horizon is suitable for examining future changes (Fellows, 2016. Adamopoulos, 2013. Braithwaite, 2018). After content analyzing the interviews, the following interviews were semi-structured. All interviews were conducted between April and July 2021. The duration of the interviews varied from 22 to 80 minutes. At the beginning of all the interviews, the participants were aware of the purpose of the study, and informed consent was obtained from them\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e The transcription of the recorded interviews was analyzed with a content analysis approach and using MAXQDA 2018. The content analysis method was used as suggested by Erlingsson and his colleagues (Erlingsson, 2017).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeveloping the mind map\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA mind map model helps provide efficient, accurate, and creative solutions. This tool can expand thinking in all fields of education, work, and human life (Chen, 2008) by visualizing insights related to the subject of study and developing relationships between ideas. Concepts, keywords, colors, and images can be used to prepare a mind map\u0026nbsp;while the vital concept is placed in the center, and other concepts branch from it (Buzan, 2005. Buzan, 2018). A mind map is rooted in cognitive structures, and understanding this map is easier for the audience than written texts (Harkirat, 2011).\u003c/p\u003e\n\u003cp\u003eThe purpose of the second phase was to categorize the ideas and draw a cognitive map of the future changes in the hospitals. Two expert panels were held in October 2021, and the second 11 days apart virtually with the sky room platform. The participants in this phase were selected purposefully among the first phase participants based on the inclusion and exclusion criteria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe first panel presented the changes resulting from phase one to experts. The experts categorized the changes and labeled them by the facilitator\u0026rsquo;s guide. With permission, note-taking was done during the meeting by two researchers. After finishing the first panel, the research team drew a mental map of the hospital\u0026rsquo;s future changes using Visio 2016.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter mapping the mind map, the second meeting of the expert panel was held. The drawn map was presented during the second session, and the participants issued potential enhancement or edition points. Finally, the amendments were applied according to the expert\u0026rsquo;s opinion.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTo determine the future changes affecting the hospitals, 33 people were interviewed in the first phase. The characteristics of the participants in this phase are presented in table number one (table 1).\u003c/p\u003e\n\u003cp\u003eTable 1. Characteristics of participants in phase one\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.035360678925034%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eOrganization\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.083451202263085%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eRole/task\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.881188118811881%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eNumber\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.035360678925034%\"\u003e\n \u003cp\u003eMinistry of Health and Medical Education\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(MOHME)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"63.083451202263085%\"\u003e\n \u003cp\u003eSpecialists of Research and Technology Vice-Chancellor\u003c/p\u003e\n \u003cp\u003eSpecialists of the Vice-Chancellor of Education\u003c/p\u003e\n \u003cp\u003eSpecialists of the Vice-Chancellor of Treatment\u003c/p\u003e\n \u003cp\u003eSpecialists of the Deputy Food and Drug Administration\u003c/p\u003e\n \u003cp\u003eSpecialists of the vice president of development and management and planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.881188118811881%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.035360678925034%\"\u003e\n \u003cp\u003ehealth insurance\u003c/p\u003e\n \u003cp\u003e(HI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"63.083451202263085%\"\u003e\n \u003cp\u003eSpecialists of the Social Security Health Insurance Organization\u003c/p\u003e\n \u003cp\u003eSpecialists of Iran Health Insurance Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.881188118811881%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.035360678925034%\"\u003e\n \u003cp\u003eHealth care Provider\u003c/p\u003e\n \u003cp\u003eHP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"63.083451202263085%\"\u003e\n \u003cp\u003eGeneral practitioner\u003c/p\u003e\n \u003cp\u003especialist\u003c/p\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.881188118811881%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.035360678925034%\"\u003e\n \u003cp\u003eHospital Management\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eHM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"63.083451202263085%\"\u003e\n \u003cp\u003eHospital managers\u003c/p\u003e\n \u003cp\u003eHospital supervisors\u003c/p\u003e\n \u003cp\u003eOfficials of quality improvement units\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.881188118811881%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.035360678925034%\"\u003e\n \u003cp\u003eResearchers and faculty members\u003c/p\u003e\n \u003cp\u003eRFM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"63.083451202263085%\"\u003e\n \u003cp\u003eResearchers in the field of health economics, health service management, health technology assessment, and futures studies in health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.881188118811881%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp dir=\"LTR\"\u003eBy content analyzing the interviews in phase one, 144 elements of change were identified. Some of them are mentioned as follows.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants stated that hospitals would become smaller but more specialized in the future. \u0026quot;...\u003cem\u003ehospitals will only focus on patients for whom the other health system providers will not have the necessary facilities and expertise, and patients with complex conditions will be referred to them from other levels, and simpler cases will also be at other levels. To be treated\u003c/em\u003e...\u0026quot; (MoH).\u003c/p\u003e\n\u003cp\u003eHospitals will have an active, patient-oriented, and user-friendly social role.\u0026quot; \u003cem\u003eProviding services will not be limited to hospitals. Hospital teams in the community will actively promote the lifestyle and treatment of patients in their homes..\u0026rdquo; (HP). \u0026quot;Due to factors such as the growth of technology and information; The quality and safety of services will increase, the preferences of patients will be taken into account in the design of spaces, processes, and services of hospitals\u003c/em\u003e...\u0026quot; (HM)\u003cspan dir=\"LTR\"\u003e.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere will be an increase in the patient\u0026rsquo;s and health force\u0026rsquo;s mobility. \u0026quot;Due to megatrends such as globalization or trends of increasing immigration and urbanization, we will see patients and health workers with different cultures from different cities and countries every day...\u0026quot; (RFM)\u003c/em\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e.\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA change in the characteristics of the health workforce will occur. \u0026quot;\u003cem\u003eWith the arrival of the millennial generation, we will see rapid and large changes in the expectations of employees from work environments. The retirement age will increase to compensate for the lack of workforce and skills\u003c/em\u003e\u0026quot; ( MoH).\u003c/p\u003e\n\u003cp\u003eNational and international cooperation and interactions of hospitals with each other and related stakeholders will increase.\u003cem\u003e\u0026nbsp;\u0026quot;...health tourism will flourish..., national and international standards and institutions supervising the activities of hospitals will increase, and hospitals will form a network with each other and use each other\u0026apos;s resources and experiences\u0026quot; (RFM). \u0026quot;As the role of hospitals in improving the health of communities increases, they will need to cooperate with different stakeholders because they can not achieve this goal lonely\u0026quot; (HM)\u003c/em\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e.\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eChanges in developed countries will happen faster than in developing countries. Also, the rate of change has increased compared to the past\u003cem\u003e.\u0026quot; In my opinion, due to trends such as globalization and international communication, several changes are common between developed and developing countries, such as technologies; the only difference is that usually, These changes in those [developed] countries have either already happened or their speed and\u0026nbsp;\u003c/em\u003eintensity\u0026nbsp;\u003cem\u003eare more significant than in developing countries..., another point that comes to my mind is the speed of changes. We constantly change in the workforce. Or we had the expectations of the patients, but the only thing that has happened now is that due to the growth of technologies such as the media and the Internet, their speed has now increased\u003c/em\u003e...\u0026quot; (RFM). Another point that can be extracted from this interview is that some changes will facilitate and accelerate other changes. For example, developing health monitoring technologies will enable the development of home care services for patients\u003cspan dir=\"LTR\"\u003e.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eIn the future, we will see changes in the composition and pattern of diseases\u003cem\u003e. \u0026quot;Clearly, due to the increase in life expectancy and the population aging, it can be predicted that the burden of chronic diseases will increase, even in my opinion, the state of multiple diseases and physical and mental diseases will increase together...\u0026quot; (RFM). \u0026quot;Climate changes, drought or global warming and even water and food insecurity that we are witnessing now, can potentially change the patterns of chronic and infectious diseases\u0026quot; (RFM). \u0026quot;The experience of Covid-19 also showed that the threats of emerging and re-emerging infectious diseases can always exist, so future hospitals should not neglect these issues\u0026quot; (MoH)\u003c/em\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e.\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEnvironmental scanning units will be activated in future hospitals. \u0026quot;Hospital administrators will be aware of the importance of political, social, and economic changes in the hospital environment and will monitor them. In my opinion, future hospitals will establish active environmental monitoring units\u0026quot; (HM).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe role of the private sector and attention to financial efficiency will increase due to the lack of resources and the increase in technological costs\u003cem\u003e. \u0026quot;Hospitals will increase partnerships with private sectors and non-governmental organizations to attract more resources..., strategic purchasing will be done more carefully\u0026quot; (HI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe growth of technology will move forward faster and affect all sectors of the healthcare system\u003cem\u003e. \u0026quot;In my opinion, using cryptocurrencies and technologies such as blockchain will increase hospitals\u0026apos; financial and information transfers. It would help if you considered that with the growth of big data and the increase in its use, blockchain could be used to maintain this information in the health system\u0026quot; (HI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;In the past years, we consider a significant growth in health technologies, wearable health sensors that help patients control health parameters are one of them. I hope hospital information systems will use this information in the future\u0026quot; (HP). \u0026quot;The development of information analysis methods such as cloud computing can greatly help health systems analyze big data\u0026quot; (RFM).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA change in norms will happen\u003cem\u003e. \u0026quot;Associations supporting patients\u0026apos; rights will become more and more active. Due to the growth of social networks, patients will be able to form a network with each other and express their expectations loudly\u0026quot; (RFM). The problems of life and the rush and stress that people have now will cause them mental issues; in my opinion, attention to spiritual health will also increase (HP)\u003c/em\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e.\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the second phase, 12 experts were selected among the participants of the first phase. Table two shows the participants\u0026apos; characteristics in the panel of experts (table number 2).\u003c/p\u003e\n\u003cp\u003eTable 2. Details of participants in the expert panel\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.325842696629216%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eOrganization\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.03049759229535%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eRole/Tas\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.643659711075442%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eNumber\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.325842696629216%\"\u003e\n \u003cp\u003eMinistry of Health and Medical Education(MOHME)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"47.03049759229535%\"\u003e\n \u003cp\u003eVice President of Development and Management and Planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.643659711075442%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.325842696629216%\"\u003e\n \u003cp\u003ehealth insurance\u003c/p\u003e\n \u003cp\u003e(HI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"47.03049759229535%\"\u003e\n \u003cp\u003eexpert of Iran Health Insurance Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.643659711075442%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.325842696629216%\"\u003e\n \u003cp\u003eHealth care Provider\u003c/p\u003e\n \u003cp\u003eHP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"47.03049759229535%\"\u003e\n \u003cp\u003eGeneral practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.643659711075442%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.325842696629216%\"\u003e\n \u003cp\u003eHospital Management\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eHM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"47.03049759229535%\"\u003e\n \u003cp\u003eHospital managers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.643659711075442%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.325842696629216%\"\u003e\n \u003cp\u003eResearchers and faculty members\u003c/p\u003e\n \u003cp\u003eRFM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"47.03049759229535%\"\u003e\n \u003cp\u003eHealth services management, health economics, health technology assessment, and futures studies in health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.643659711075442%\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp dir=\"LTR\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eTo prepare the mind map framework, the experts categorized the future changes into ten main categories as follows:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eStructure and role\u003c/li\u003e\n \u003cli\u003eManagement of knowledge and research\u003c/li\u003e\n \u003cli\u003eService delivery\u003c/li\u003e\n \u003cli\u003eHealth forces\u003c/li\u003e\n \u003cli\u003ePolitical and legal issues\u003c/li\u003e\n \u003cli\u003eEconomic\u003c/li\u003e\n \u003cli\u003ePopulation and disease\u003c/li\u003e\n \u003cli\u003eTechnological issues\u003c/li\u003e\n \u003cli\u003eValues and Philosophy\u003c/li\u003e\n \u003cli\u003eEnvironmental issues\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAnd in the next step, the concepts\u0026apos; cognitive map was drawn with experts\u0026apos; participation and insights (Figure 1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe speed of changes in the 21st century is faster than in previous years (Rechel, 2009). Health care is not excluded from these changes and is one of the most complex and growing industries worldwide (Preker, 2016). Hospitals are also one of the critical components of health systems. Hospital services constitute about 50% of the total health costs (Levaggi, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). It is necessary to pay attention to hospitals to improve the overall performance of the health system (Ehler, 2018). The present study showed that the future of hospitals is affected by many factors interacting inside and outside the hospital\u0026rsquo;s scope and health system.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStructure and role\u003c/h2\u003e \u003cp\u003eIn the future, hospitals will become specialized and small places where services will not be provided by other health service providers and will be exclusive to them. Less technical and palliative services will be transferred to primary care providers, nursing centers, or patients' homes. Besides, integrating specialized services in hospitals will keep them in the servicedelivery line to respond to society's needs. Their number will be reduced, or they will not be constructed without a needs assessment. Barber also points out in his study that the speed of establishing hospitals will be slower in the future, and they will probably face stricter controls on construction and size (Barber, 2014). Also, the congestion in hospitals will decrease over time. However, diseases and more complex treatment methods will remain in the future hospital, making them more specialized and smaller (Zimlichman, 2019).\u003c/p\u003e \u003cp\u003eFuture hospitals will network with other health care providers to share knowledge, experiences, and resources. They will collaborate to identify and respond to community health needs. The network structure allows for economies, proper consumption of resources, development of innovative capabilities of hospitals, reduction of the negative aspect of competition between hospitals, creation of a sustainable market-based health system, and ensuring effective care of patients (Ill\u0026eacute;s, 2016. Mascia, 2015). The map of the related structural and role elements is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge and research\u003c/h2\u003e \u003cp\u003eFuture hospitals will play a more active role in knowledge production by using different research methods and knowledge translation. These hospitals will provide the context of the activities of researchers and facilitate start-ups. Attention to social medicine and educational issues will be strengthened. Health environmental monitoring units will be established to identify and manage existing and future changes and trends. Due to rapid growth and progress in the health system, the field of \"health innovation\" will be supported, and it examines and monitors health developments and innovations at the global level to increase confidence and reduce risks (Dawe, 2015). The knowledge and research related elements of the future changes is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e as follows.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eService delivery\u003c/h2\u003e \u003cp\u003eHospitals will continue their service delivery through multidisciplinary teams and teamwork-based. Patient-centered and providing teamwork services will be necessary to meet the needs of the future (Mokhtar, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Absolute coordination with other providers is another point. Schurr quotes Thomas Bodenheimer \"\u003cem\u003ePatients with multiple chronic diseases are likely to see about 16 doctors a year. In the meantime, treatments and diagnostic processes may be repeated by doctors, which is dangerous and also costly for patients\u003c/em\u003e\" (Schurr, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). One example of lacking the integrated model of services delivery is patient mortality, about one-third of deaths in the United States are due to acute myocardial infarction in the post-hospital discharge phase (Cherlin, 2013). These problems need even more coordination between hospitals and health service providers in the future to ensure the population\u0026rsquo;s health and prevent and reduce errors. The map of the \u003cspan refid=\"Sec12\" class=\"InternalRef\"\u003eservice delivery\u003c/span\u003e section is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHealth forces\u003c/h2\u003e \u003cp\u003eIn the future, the hospital staff will be of new generations with different characteristics than past ones. Generation Z was born after 1995; they grew up in the internet world and are used to technology. As mapped in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, their characteristics are self-reliance, freedom, high use of technology, and desire for speed. They are primarily online and spend little time in the real world, reinforced by metaverse. This generation wants a balance between work and personal life, friendly relationships in the workplace, support for personal development, and an opportunity to flourish and prove themselves (Bieleń, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Managers should make work environments attractive to retain and attract them. Flexible working hours and territories are among these factors. One of the critical issues predicted for the future health system workforce is the need for interdisciplinary competencies and the ability to work in collaborative teams. In recent years, there has been increasing pressure in higher education to train graduates in the health system with the capabilities to work effectively in collaborative and interdisciplinary teams to solve critical issues. For this purpose, the approach to interprofessional education has been developed (Brewer, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). More emphasis will be placed on increasing health literacy among hospital staff. It is assumed that high health literacy among health workers will improve patients' health literacy. There is a positive relationship between health literacy and the health status of the population and a negative association with health inequalities (Budhathoki, 2019). Due to its importance, hospital and university managers must take interventions regarding improving the health literacy of the future forces of the health system.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePolitical and Legal\u003c/h2\u003e \u003cp\u003eRechel states that are regulating hospitals and their services are not only a technical or managerial issue but a political decision to a great extent (Rechel, 2009). Various political and legal trends will affect the future of hospitals. In the present study, the experts pointed out that locating the Middle East and the continuous conflicts and terrorism in this region, the threats caused by these factors should always be considered by the future planners of hospitals. Political communication and exchanges between countries have grown in recent years and have expanded the phenomenon of globalization. Globalization is a multi-dimensional and complex process that is also related to health and can potentially increase access to health care. The openness of import and export will increase competition among companies and affect working conditions and wages, indirectly affecting society\u0026rsquo;s health. Globalization increases the possibility of spreading infectious diseases such as COVID-19, but can improve the quality of health in low-income countries on the other side (Yang, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In today's world, governments try to communicate with each other and use their potential for growth and development. Globalization provides an opportunity for the health systems of mainly developing countries to learn from best practices worldwide or to attract resources for their growth by establishing active health diplomacy. The political and legal elements of change is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEconomical\u003c/h2\u003e \u003cp\u003eAs also presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e, Cancer mortality is higher in individuals with no insurance (Nolan, 2022) showing the importance of insurance for chronic diseases on the other side society's demand for insurance coverage for chronic and palliative diseases will increase with the rise in the population\u0026rsquo;s average age and elderly-related diseases.\u003c/p\u003e \u003cp\u003eMarketing skills will be another key tool for success in health systems and especially hospitals in the future. Service research, service design, and strategic aspects of marketing are vital factors in designing and providing future health services (Sidney, 2018). Managers and decision-makers need to empower future hospitals and their workforce to gain an advantage in this regard.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePopulation and disease\u003c/h2\u003e \u003cp\u003eThe risk of emerging and spreading infectious diseases is rapidly increasing due to global environmental changes and increased migration (Lee, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The experience of the Covid-19 spread shows that emerging diseases could turn into a pandemic and affect all aspects of life, such as social, economic, and health. It would be simplified to plan and design future hospitals merely based on chronic or elderly-related diseases. Covid-19 had many lessons in this regard and considered the flexibility of hospitals for potential upcoming challenges.\u003c/p\u003e \u003cp\u003eIn addition to considering infectious diseases, it is a fact that the world's population is aging due to declining fertility rates and increased life expectancy (Uhlenberg, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). According to the World Health Organization, about 40\u0026nbsp;million people need palliative care every year. About 78% live in low-income and middle-income countries, and only about 14% of people who need palliative and end-stage care receive it. In the past decades, treatments' complexity has increased in hospitals' end-of-life care (De Roodenbeke, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). In the future, special attention will be paid to hospitals to provide services to chronic patients and palliative care. It will be necessary for hospitals to form a network with informal providers inside patients' homes and care centers outside the hospital and support them technically.\u003c/p\u003e \u003cp\u003eAntimicrobial resistance is another challenge for the future of global health. This challenge can potentially damage billions of dollars annually to the global economy and treat the lives of 10\u0026nbsp;million people by 2050 (O'Neill, 2016). It is necessary to constantly remind hospitals of these issues and use their scientific potential, equipment, and staff to proactively approach these future-related matters. The demographic and diseases-related elements are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTechnology\u003c/h2\u003e \u003cp\u003eOne of the emphasized future changes is technology development, advancing faster than ever for hospitals. It has been mentioned that digital health is one of the main drivers of any change in the future of health systems (Herrmann, 2018). Many advances in wearable sensors, mobile health technologies, information technology, telemedicine, and network systems have provided the way to provide health services and the possibility of remote monitoring of health parameters, especially for chronic patients, which results in effective disease management\u0026mdash;and improving the patient's quality of life (Rajagopalan, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2019\u003c/span\u003e. Vespa et al. 2010). Intelligent and comprehensive health systems use technologies through which patients can self-manage their health symptoms. These technologies will improve treatment decisions at the right time and medication adherence (Rajagopalan, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith new, more effective, and personalized medicine, patients are living longer, and many previously incurable diseases are now well managed as chronic diseases (Schurr, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Along with the many advantages of technology, it should be noted that it can significantly increase health costs. It is also important to note that these technologies do not always lead to improved clinical outcomes. Safety is also one of the issues of technology (Sampietro-Colom, 2016). In future hospitals, it will be necessary to have a systematic, transparent, and impartial evaluation of health technology. The technological-related elements of the map are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eValues ​​and Philosophy\u003c/h2\u003e \u003cp\u003eChanges in concepts, principles, and values ​​of different stakeholders of hospitals have started and will continue. Patients are transitioning from passive recipients of services to active ones. Their expectations for value, satisfaction, and experience are also increasing (Sidney, 2018). Laurent Gille and colleagues acknowledge that determinants of health care demand will change. They believe that in the medium and long term, the emphasis will no longer be on the right to have an effective treatment but on the duty of being healthy, showing a shift from \"right\" to \"duty\" (Gille, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the future, hospitals will make more use of patients' participation in treatment processes. One option would be to change the name of the hospitals from \"Hospital\" to \"Health Homes.\" Empowering and improving patients' living conditions will be one of the missions of hospitals, which will improve health outcomes and reduce the workload of hospitals. Ahn also points out that empowering people with chronic diseases to manage their conditions will improve health and lower costs (Ahn et al. \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The values and philosophy-related elements are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eEnvironmental\u003c/h2\u003e \u003cp\u003ePollution of air, water, and soil has increased dramatically due to industrial reasons and the use of vehicles in the past years and is predicted to increase more if there is no intervention in this regard. It is also expected that the most significant increase in pollution will be seen in the cities of low and middle-income countries and rapidly industrializing countries (Lelieveld, 2015). Air pollution in developing countries, like Iran, is also a significant health challenge (Mojarrad, 2020). Unfortunately, Iran ranks fifth in the world in terms of plastic consumption, which is high. Nearly half a million tons of plastic are used in Iran annually, and about 5000 tons of plastic are produced as waste daily. Pollution caused by plastic particles can have many health risks (Khayamabshi, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). All forms of pollution were the reason for about 9\u0026nbsp;million premature deaths in 2015, or 16% of all deaths worldwide. It is also estimated that about 268\u0026nbsp;million disability-adjusted life-years (DALYs) occur due to pollution (Abdulmuhsin, 2016). Climate change is another challenge that has intensified in the past decades. This challenge affects the health of communities through climate change, the spread of infectious diseases, changes in the workforce's capacity, and the effect on food security (Di Napoli, 2022). Unfortunately, Middle East countries will experience the negative consequences of climate change more than other countries in the world (Sharafati, 2022). It is estimated that by the year 2100, the average temperature in most regions of Iran will increase by more than 4 degrees Celsius (Borna, 2011). Therefore, it seems that diseases related to pollution and climate change will plague future hospitals. More information of the environmental future changes are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eMany of the changes mentioned in this study started in the past and will continue in the future and the point is in the increasing intensity and speed of changes. The study scope was Iran as a developing country in a time horizon of 15 years. Also, the occurrence of one or more wild cards may affect the mentioned trends, but the absolute point is that the future of hospitals will have profound changes in terms of structural, political, and health forces; and it will be helpful for future studies to identify these wild cards and evaluate their effects on future changes. These changes have synergies and interactions that alternatives of their future status shape different scenarios and it is suggested to conduct studies in this regard. Another suggestion of the current study is to establish environmental monitoring units both at the macro level of the health system and in the hospitals to monitor changes for informed decision-making and planning. The main limitation of the current study was the outbreak of the Covid-19 disease at the time of the study, which caused problems in receiving interviews and holding expert panels, which the research team tried to solve by using virtual communication facilities. This study summarized and categorized the future changes in hospitals in the form of a mind map. Considering the advantages of the mind map, we hope that the future managers of the health system and hospitals will act with a more open vision and a future-thinking approach to plan for the future. According to Erwin's opinion, hospital managers need to ask themselves whether their current management approach is optimal or not (Erwin, 2019).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to all\u0026nbsp;participants who contributed to this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was done with ethical approval and consent to participate.\u003c/p\u003e\n\u003cp\u003eThis study is a part of the Ph.D. thesis phase entitled \u0026ldquo;Analyzing the competence development policies of hospital managers and presenting policy packages\u0026rdquo; with the code of ethics IR.KMU.REC.1399.299. It has been approved and is being implemented at Kerman University of Medical Sciences, Iran.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBuzan T, Abbot S. The Ultimate Book of Mind Maps: Unlock Your Creativity. boost Your Memory, Change Your Life 2005. London: Thorsons.\u003c/li\u003e\n\u003cli\u003eBorna R, Roshan G, Shahkoohi AK. Global warming effect on comfort climate conditions in Iran. Advances in Environmental Biology. 2011 Nov 1:3511-8.\u003c/li\u003e\n\u003cli\u003eArab-Zozani M, Pezeshki MZ, Khodayari-Zarnaq R, Janati A. Inappropriate rate of admission and hospitalization in the iranian hospitals: a systematic review and meta-analysis. Value in Health Regional Issues. 2020 May 1;21:105-12.\u003c/li\u003e\n\u003cli\u003eJafari M, Nemati A, Aboulhallaje M. Governance in Iranian public hospitals. 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Accessed 30 July 2022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mind map, future, changes, hospital","lastPublishedDoi":"10.21203/rs.3.rs-2004067/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2004067/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eHospitals have a vital role in the future of health systems but will change. Identifying the potential aspects of change helps managers have a proactive approach in dealing with them, make use of the opportunities, and avoid threats. This study presents a mind map of future changes in Iranian hospitals to develop a base for further related studies or prepare evidence for interventions and future-related decisions.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThis study is a qualitative-exploratory one, conducted in two phases. In the first phase, in-depth and semi-structured interviews were conducted to identify the future changes of the hospitals over a 15-year time horizon. The interviews were analyzed using the content analysis method and MAXQDA 2018 software and holding two expert panels to develop the mind map using the 2016 Visio software.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eIn the first phase, 33 interviews led to 144 change patterns. In the second phase, a mind map of changes was drawn according to experts' opinions with ten categories: structure and role, knowledge management and research, service delivery, health forces, political and legal, economic, demographic and disease, technological, and values and philosophy, and environmental.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eMany changes affecting hospitals rooted in the past continue to the future, but the point is the increasing intensity and speed of changes. Health care systems need a systematic approach to monitoring the environment to be updated, agile and proactive. These monitoring systems are essential in providing evidence for Macro-level decision makers.\u003c/p\u003e","manuscriptTitle":"What is the mind map of the hospital's future changes in a developing country like Iran? 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