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Depiction of Health. 2024;15(1): 64-83.
doi: 10.34172/doh.2024.06
  Abstract View: 311
  PDF Download: 169

Health Economics

Original Article

Compilation and Validation of a Comprehensive Model of Performance Audit in the Field of Health Using a Fuzzy Delphi Method

Hojjat Esmati Beyrami 1 ORCID logo, Aliasghar Mottaghi 1* ORCID logo, Younes Badavar Nahandi 1 ORCID logo, Ahmad Mohammady 1 ORCID logo

1 Department of Accounting, Faculty of Management, Economics and Accounting, Tabriz Branch, Islamic Azad University, Tabriz, Iran
*Corresponding Author: Email: Aliasghar.Mottaghi@yahoo.com

Abstract

Background. Measuring the efficiency, effectiveness and economic efficiency in the public sector and accordingly allocating resources based on the accepted indicators leads to an increase in public welfare. This study aimed to develop and validate a comprehensive model of performance audit in the field of health.
Methods. This study was carried out using a mixed methods approach. Data in the qualitative section was collected by non-probability sampling method and conducting in-depth interviews with 16 experts and senior managers in the field of performance auditing. In the quantitative section, using Cochran’s formula, the sample size was estimated as 384 individuals. Data was collected using a questionnaire, the fuzzy Delphi method, and the partial least squares (PLS) regression in the MAXQDA 2020 software. The collected data was validated through a questionnaire to obtain the final research model.
Results. Findings of this study indicated that the following indicators played a vital role in better implementation of performance audits in the field of health: staff empowerment, employing expert and efficient human resources, developing appropriate rules and regulations, managing internal organizational goals, organizing the organization, exercising control over internal policies, economic factors within the organization, laying the foundation for the implementation of performance audits, and organizational productivity.
Conclusion. According to the results of the present study, the extracted performance audit indicators can be used to evaluate and improve the quality of performance audit in various areas of health sector.


Extended Abstract

Background
In most countries, healthcare expenses comprise one of the largest annual budget expenses. In Iran, the Ministry of Health and Medical Education receives the second largest portion of the national budget, following the Ministry of Education. However, the costs incurred by various ministry departments, including education, treatment, health, and medicine must be classified properly. The cost of the provided services must be accurately computed and reported. On the other hand, public sector managers, particularly in the health sector, are expected to provide appropriate criteria for evaluating their performance due to the increased demands of the public and the government budget deficit over the past few years.

There is a pressing need to develop a comprehensive and detailed financial circulation process model to enhance the whole system of fitting financial performance in a non-isolated system. This system operates in a stable environment and interacts with other financial circulation institutions, whether at a level of complete independence or high dependence. This study aimed to develop and validate a comprehensive model of performance audit in the field of health.

Methods

This study applied a mixed-methods research design, and the population consisted of auditing experts. Data collection in the qualitative section was done through non-probability sampling using in-depth and semi-structured interviews with 16 experts, stakeholders, and senior managers in the field of performance auditing. In the quantitative section, the sample size was determined to be 384 using Cochran's formula for screening and identifying final performance auditing indicators in the public health sector based on previous research. The panel members consisted of university professors in the field of performance auditing, as well as experienced managers and experts, especially those who had experience working in the public health sector. New indicators were added through interviews with panel members and using expert opinions; meanwhile, some repetitive indicators were removed. We used a researcher-made questionnaire. To test the validity and reliability of the questionnaire, convergent validity, composite reliability, and Cronbach’s alpha were used. In the next stage, fuzzy Delphi method was used for validation and screening of indicators. Fuzzy numbers with a 7-degree fuzzy spectrum were used to fuzzify expert opinions, and through two rounds of fuzzy operations, defuzzification was performed. The obtained values were compared with each other using partial least squares (PLS) technique in MAXQDA2020 software for data validation. Finally, 21 indicators were identified, and the final research model was obtained.

Results

The extracted indicators were validated using the fuzzy Delphi method in two phases. No indicators were eliminated in the mentioned phases, signifying the conclusion of the Delphi rounds. If the difference between the two phases was less than the extremely low threshold (0.2), the survey would be terminated. The model was finally validated using the partial least squares (PLS) regression and SmartPLS 4 software.

The factor loading for the effect of empowering and employing expert and efficient personnel was 0.302, establishing the groundwork for the implementation of performance audit. Moreover, the t-statistic value was equal to 5.715. Therefore, it can be asserted with 95% confidence that empowering and employing knowledgeable and effective personnel had a positive and significant effect on the implementation of performance audits.

The factor loading for the effect of the formulation of appropriate rules and regulations was greater than or equal to the implementation of the performance audit (0.175). Moreover, the t-statistic value was equal to 4.130. Consequently, it can be asserted with 95% confidence that the formulation of appropriate laws and regulations had a positive and significant effect on the implementation of performance audits.

The factor loading for the impact of intraorganizational economic factors was greater than or equal to the implementation of the performance audit (0.455). The value of the t-statistic was equal to 9.314. Thus, it can be asserted with 95% confidence that intraorganizational economic factors had a positive and significant effect on the implementation of performance audits.

The factor loading for the impact of implementing performance audit was greater than or equal to management of intraorganizational objectives (0.687). In addition, the t-statistic value was equal to 24.415. Therefore, it can be asserted with 95% confidence that implementing performance audits had a positive and significant effect on the management of intraorganizational objectives.

The factor loading for the impact of implementing performance audit was greater than or equal to implementing control on internal policies (0.676). In addition, the t-statistic value was equal to 22.954. Therefore, it can be asserted with 95% confidence that the implementation of performance audit had a positive and significant effect on controlling the internal policies.

The factor loading for the effect of control on internal policies was greater than or equal to organizational productivity (0.358). Additionally, the t-statistic value was equal to 6.709. Consequently, it can be asserted with 95% confidence that exercising control over internal policies had a positive and significant effect on organizational productivity. The coefficient of standard estimation for the effect of control over internal policies on organizing was found to be 0.277. Moreover, the t-statistic value was equal to 4.268. Therefore, it can be asserted with 95% confidence that exercising control over internal policies had a positive and significant effect on the organizing of the organization.

The factor loading for the effect of intra-organizational goal management on organizational productivity was equal to 0.461. Also, the value of the t-statistic was equal to 8.250. So, the management of internal organizational goals had a positive and significant effect on the organization's productivity.

The factor loading for the impact of intra-organizational objectives management on organizing was equal to 0.496. In addition, the t-statistic value was equal to 7.447. Thus, the management of internal organizational objectives had a positive and significant effect on the organizing of the organization.

Accordingly, the following concepts were obtained for contextual conditions: establishing standards, laws and requirements, applying control, and monitoring policies and laws. For causal conditions, the items were as follows: increasing knowledge and skills, training performance audit, having capable human resources, using the expert force, and increasing expert teams with cooperation and establishment of relationships. For central phenomena, the items were as follows: creating an environment for performing performance audit, support and acceptance to perform performance audit, increasing executive guarantee, and strengthening performance audit. For strategies and measures, the items were as follows: the system of preparing and strengthening the budget control system, transparency of financial reporting, quality management to achieve goals, and determination and comparison of predetermined goals. For intervening conditions, the items were as follows: application and appropriate use of operational budgeting, determination of scales economic efficiency, and the role and place of measuring and valuing resources. Finally, these categories were also identified: implementing and establishing the calculation of the finished price of goods and services, determining and improving the key indicators of the organization’s performance, increasing the motivation for research, and using the system information was obtained.

Conclusion

The findings of the present study showed that the indicators provided for performance audit evaluation have good validity and reliability. Therefore, these indicators can be used in different parts of the health sector as well as in other public sector organizations as a model for conducting performance audits in order to improve efficiency and effectiveness.

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Submitted: 04 Jul 2023
Revision: 11 Dec 2023
Accepted: 30 Dec 2023
ePublished: 03 Feb 2024
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