Introduction

One of the fundamental factors of an organization's success is accountability [1]. Accountability in organizations that provide health services is defined as the responsibility of an individual or an organization regarding its actions and performance [2]. Accountability in hospitals refers to responsibility for the overall quality and safety of care [3]. Hospital governance can be defined as the set of structures and processes that define the strategic direction for the hospital and the means by which resources are assembled and allocated to achieve them [4]. Hospital governing bodies have a fundamental role in overseeing quality and safety by defining priorities and objectives, crafting strategy, shaping culture, and designing organizational control systems [3]. An accountability regime will always be based on three elements: a clear definition of desirable goals or objectives (the object of accountability), the ability to measure and monitor goal achievement, and a set of consequences for providers or organizations if achievements regarding goals or objectives are not satisfactory [5] In recent years, improving the accountability of healthcare organizations has been one of the main motivations for reforms in health systems [2]. Studies have introduced accountability as a tool for increasing transparency and improving healthcare quality [6, 7].

However, in developing countries, health sector reforms have concentrated primarily on increasing financial accountability and have paid less attention to other forms of organizational accountability [8]. The Health Services Delivery Program of the World Health Organization introduces five components of accountability: a) legal accountability, which includes planning, contracting, and budgeting; b) financial accountability, which includes tracking and reporting on fund allocations, funds disbursement, and ethical use of resources; c) professional accountability, which promotes service delivery according to legal, ethical, and professional standards; d) political accountability, which ensures that governments fulfill public trust, represent the public's interest, and respond to societal needs and concerns; and e) public accountability, which includes public engagement at all levels and appropriate structures to support information flow between decision-makers and different public involvement fora [9].

The concept of accountability has traditionally been drawn somewhat narrowly by public lawyers to encompass the formal duties of public bodies to account for their actions to ministers, parliament, and courts [10], so a common understanding of hospital governance accountability is where an upstream entity such as a government, regional health agency, board of trustees, or professional association can hold providers or organizations accountable for achieving specific goals or objectives [5]. Hospital governance might promote or undermine health performance [11, 12]. The governance structure defines the strategic direction, objectives, policies, legislation, regulations, and programs and monitors and assesses their achievement [13]. In this study, we consider both internal and external accountability.

Hospital governance leadership differs from other institutions or industries [14,15,16,17]. The external environment of the hospital is constantly under the pressure of public opinion and governments to spend resources more efficiently [14]. The internal environment of the hospital has various independent specialists, such as physicians, nurses, paramedics, financial affairs, and management professionals, who communicate and make them accountable for achieving hospital goals, which is a complex matter [18].

Hospital leaders should question whether the current organizational governance structure is optimal for converting inputs into clinical and financial outputs [19,20,21]. The perceived problems in ensuring the accountability of hospitals and the efficiency of their performance led governments to various governance structure initiatives. Autonomous hospitals, corporate hospitals, hospitals with boards of trustees, hospitals with public‒private partnerships, and budgetary hospitals are examples of these structural initiatives [22, 23]. These structural reform initiatives had different positive and negative outcomes [23].

Clinical professionals try to achieve health goals, and the management team tries to achieve financial and management goals in their way. This shows the necessity for aligning these teams to a specific and robust hospital administration and management structure. The point where many of them are the most critical problem in hospitals is existing clinical and nonclinical parts and making both parts accountable [18, 24, 25]. Hospital governance refers to the balancing mechanisms and controls that shape the decision-making process in hospitals. Clinical participation and management professionalism are essential aspects of the governance structure in a hospital [20]. Clinical and nonclinical actors have different patterns of thinking and doing at different organizational levels in hospital districts and different perspectives on accountability. In this setting, the gap between managerial identity accountability (i.e., to comply with governance policies issued by the political institution) and the accountability of medical professionals in their domain leads to accountability tensions [26].

Hospital decision-making is a complex and often diffuse process involving key people, including physicians, administrators, and boards. Physicians are essential in clinical decisions and should be accountable for high-quality, safe care. Administrators influence hospital policy and planning activities [27]. Medical staff usually involved in the hospital governance structure as board members or organized in a separate structure have been called under various names, including medical staff council or medical advisory committee, to create accountable clinical departments [28, 29].

The most important task of the hospital is to provide safe and quality clinical services [30]. If it is not considered in the hospital's governing structure, the capacity for this function cannot be sure of its accountability [31]. Hospital governance can only be fully understood by taking the role of the medical staff into account. Therefore, hospitals should use medical staff as financial and planning committees in their governance structure [32]. As a result, while the administrative structures of the hospital are legally responsible for monitoring quality and safety, they delegate authority for monitoring quality and safety in the scope of the medical staff council [21].

A typical model of hospital governance to overcome accountability problems is adding upstream structures, such as the Board of Trustees, to the hospital governance structure [33, 34]. Having a professional, vigilant, independent board greatly impacts the performance of any organization, including hospitals [35]. Empowered by a strong and effective board, a well-performing hospital will be able to ensure that social obligations can be fulfilled and that patients will receive proper treatment and care while maintaining economic and financial sustainability [36]. Some studies show that a common factor in the inefficiency of various governance structures is weakness in monitoring and responding to quality issues in public hospitals [37]. The importance of governance for the accountability of health systems is broadly recognized. Despite this recognition, accountable governance definitions continue to be disputed, and arguments and confusion persist about how governance structure interventions influence hospitals' accountability and health outcomes. Governance-related linkages or interventions often need to be better understood and documented. This lack of evidence can result in reticence and hesitation to invest in hospital governance structure improvements or overreliance on a limited set of successful governance interventions [36, 38].  An accountable governance structure is necessary because public hospitals play an essential role in health systems. However, identifying the characteristics and activities of this structure to achieve accountability has received less attention. The present study aimed to identify accountable governance structures in public hospitals through a scoping review of the global research literature.

Method

Eligibility criteria

The present study uses the Arksey and O'Malley framework to examine the extent, range, and nature of research activity on the accountable governance structure in public hospitals. Arksey and O’Malley’s framework includes six stages, the sixth being optional: a) identifying the research question that it is necessary to include three parts of the research question: a) Population b) Concept c) Context (PCC question); b) identifying relevant studies, a process that is as comprehensive as possible; c) study selection, with the establishment of inclusion/exclusion criteria, based on familiarity with the literature; d) charting the data, a stage that includes sifting, charting, and sorting information according to key issues and themes; e) collating, summarizing, and reporting the results, which provides both a descriptive and numerical summary of the data and a thematic analysis; and f) a consultation exercise, an additional, parallel step involving key stakeholders to inform and validate study findings [39]. Peer-reviewed papers and the gray literature (government reports, policy documents, reports of consultants, unpublished reports) were written in English between 2010 and January 2023. Databases of ongoing research and unpublished literature were searched. According to the research question, studies about P= public hospitals, C=accountable governance, and C= all over the world were included in the study. Other inclusion criteria were published after 2010 and written in English. For gray literature, the inclusion criteria were free online full-text versions, English language, documents related to public hospitals, and the study's time frame. The exclusion criteria were missing full text, articles focused on nonhospital entities, and papers focused on accountable care organizations.

Information sources

The PubMed, Web Of Science, Embase, Scopus ProQuest databases, and Google Scholar search engine were searched. The Google search engine obtains gray literature, including reports, regulations, guidelines, and policies. Google search without a time limit based on the first 200 results added to the search regardless of date. To determine the keywords of the research, after searching the sources and consulting with the experts, the three main concepts of accountability, governance, hospital, and their synonyms were searched in different databases. The search strategies in different databases are reviewed based on the characteristics of the database and presented in Table 1.

Table 1 Search strategy summary for the scoping review
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Selection of sources of evidence

First, we entered the literature search from different databases into Mendeley software. The remaining sources are examined after removing the duplicates. Titles and abstracts were screened. In this stage, articles were excluded if they were not relevant. In the next stage, the full text of the remaining sources is screened. Moreover, they were excluded from the study if there were no relevance or exclusion criteria. Finally, the remaining articles were reviewed (Fig 1).

Fig. 1
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PRISMA flow diagram for included studies

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The included sources were reviewed. A summary was prepared. Key points of each reference were identified, and a summary, including the first author's name, the date of publication, the country, the purpose, and the main findings, was prepared (Table 2).

Table 2 Characteristics of the included studies in the scoping review in the order of publication date
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Critical appraisal of individual sources of evidence

A scoping study will need some analytic framework or thematic construction to present a narrative account of the literature. There is no attempt to present a view regarding the 'weight' of evidence about particular interventions or policies [39]. Per guidance on conducting scoping reviews and consistent with scoping reviews on health-related topics, the methodological quality of the included reports was not appraised [39, 40].

Synthesis of results

The studies were categorized based on the characteristics of the hospital governance structure, methodology, settings, and key findings. Then, topic construction was performed using the attributes of various hospital governance structures (Table 2). The strategy of data analysis in the present study is qualitative content analysis. Using qualitative content analysis is one of the usual methods for synthesizing results in scoping review studies. This method helps to obtain a summary of the data by coding [41]. The research identifies the components of governance structure and accountability of hospitals worldwide.

Results

Of the 40 sources included in the study, 85% were published in peer-reviewed journals. Moreover, 15% had organizational reports at the national or international level. Sixty-two percent of the sources were published between 2015 and 2022. Seventy-five percent were about the governance and accountability structure in hospitals, and 25% were about hospitals and other health system components. A total of 27.5% of the studies were conducted in the United States, and 37.5% were conducted in European countries and the United Kingdom. A total of 22.5% of the studies were completed with quantitative research methods and the same amount with qualitative research methods. Table 3 describes the sources used (Table 3).

Table 3 Description of included studies
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After categorizing and analyzing the data, four main themes and thirteen subthemes were extracted (Table 4).

Table 4 The main themes and subthemes of the study
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Inclusive governance

Hospitals are complex entities. Public hospitals face pressure from public opinion and politicians to be accountable for public resource usage. Additionally, the internal environment of the hospital faces various specialties. Management, economics experts, and medical and nursing staff try to achieve their goals. Aligning financial and clinical goals is challenging for hospital governance [26]. In addition, the clinical and administrative departments probably cannot be accountable to each other, so an intermediate structure is necessary to make the two departments accountable simultaneously [18, 24, 26]. For this purpose, the public hospital should use the presence of a board in its structure [19, 43, 53]. This Board can be called the Board of Trustees, the Governing Board, or the Board of Directors [42,43,44,45,46,47,48]. This structure can have medical staff members or a counterpart structure called the council of medical staff [26, 44, 45, 48, 50, 51, 55,56,57]. f [49, 50, 55, 59, 60]. Additionally, the presence of nurses' representatives in the governance structure helps to make nursing and paramedical departments accountable [50, 51, 54, 58]. Forming various hospital committees also helps minimize the gap between clinical and nonclinical groups. These committees lead to a common understanding of barriers and resources [26, 46, 52,53,54].

Commitment to accountability

Accountability has different dimensions and forms. However, developing countries are primarily satisfied with defining it as a financial issue [70]. Public hospitals consume public funds, so the public population is defined as its stakeholders [8, 44,45,46, 48, 52, 60, 61, 63]. This definition ignores their role in providing health care as the essential function of hospitals. Therefore, it needs to be considered a comprehensive definition. An essential part of hospitals' accountability is their clinical accountability. The hospital's governance structure should be committed to providing safe and high-quality care and evaluating its achievement [52, 61, 71]. Another type of accountability is the political and social accountability of the hospital. As a healthcare organization, the hospital has the role of political and social accountability and cannot ignore it. Social and political accountability includes the hospital's responsibility regarding social and political issues, emphasizing their most critical role, namely, the clinical role [45, 46, 52, 61, 64]. Social and political accountability refers to the degree to which governments and institutions deliver on promises, act in the best interest of citizens, and respond effectively to societal needs [61].

Autonomy

In traditional accountability models, hospitals should be accountable to an upstream entity such as the Ministry of Health, local health department, or university. However, implementing external accountability is complex and may not be accurate [72]. In contrast, the hospital may have a structure that goes beyond the administrative bureaucracies of government organizations to monitor its performance and take necessary measures [52, 57, 68, 69]. The hospital should be able to be accountable to its governance structure (board, council of medical staff) for all performances, including financial, clinical, sociopolitical, strategies, and operations [26, 36, 46, 52]. Having a completely independent or hybrid governance structure is a way that hospitals follow to improve their accountability. The meaning of hybrid governance is that, in addition to having an internal structure for accountability, the hospital can also be accountable to the government parts, such as the Ministry of Health, for providing safe, quality services at a reasonable cost [47, 52, 54, 55, 69].

Planning for accountability

The existence of a specific program for accountability helps all stakeholders in hospitals, including clinical and nonclinical staff, patients, and the community, to know their responsibilities and authorities. This document contains an articulated set of responsibilities and associated financial, clinical, social, and political accountabilities. Hospital staff, patients, and society know which kind of accountability structure is run in the hospital and how they can use it if needed [43, 48, 58, 65, 66]. The existence of a clear reporting line that allows each employee to know what structure and people they are responsible for helps to reduce confusion and allows employees to make correct decisions in sensitive situations and benefit from the advice of others. The reporting line will reach the hospital's governance structure, i.e., the board or council of medical staff. Employees must account for these structures regarding their performance [44, 47, 50, 52, 55, 66, 67].

Discussion

Accountability is an essential part of social relations in societies. Individuals and organizations must be held accountable for what they do or do not do. Organizations that use public funds require high levels of accountability and transparency. Accountability ensures that public funds are properly allocated and closer to their predetermined results. The concept of accountability is considered a key concept in the health system. Since hospitals use the majority of health resources in all health systems, it is necessary to be accountable. The relationship between governance structure in the hospital and accountability is clear. The governance structure in public hospitals is required to provide a basis for achieving accountability in various areas.

The hospital's governance structure must be a combination of its key stakeholders. The presence of management and economic experts, doctors and nurses, and representatives from the community in the hospital's governance structure can effectively increase its accountability. These individuals can be present on the Board, its committees, or similar structures. Atuesta et al. have shown that hospitals whose governance structure also has medical groups can provide better quality and safer services [73]. Nurses are one of the most critical groups in hospitals. The present study emphasizes their role in the hospital governance structure. This finding is in accordance with the study of Esfandnia in Iran. This study also shows that the presence of nurses in the hospital governance structure can improve patient safety [74]. The presence of community representatives on the hospital board was considered in the present study. Wright also criticizes the structure of the hospital's Board of Trustees in Britain and calls for the role of community representatives to play earnest roles [75]. The presence of these categories can provide the report line to the specialized forces in each field. The hospital is a specialized structure, and the existence of different groups in it will probably require a governance structure that can professionally manage each department and person to become accountable for their performance regardless of the type of expertise.

Although there is no unique definition of accountability, different types have been identified in different studies. The commitment of the health system and hospital managers to financial, clinical, and social-political accountability is one of the important findings of this study. Commitment to accountability is an important issue for the hospital's primary goal: clinical accountability. These findings have been confirmed in Cornock's study. In that study, the vital role of the clinical accountability of health professionals was mentioned [76]. However, some studies, such as Cornelese's study, argue that if this account is in the form of accountability to other physicians and specialists because of the psychological influence of peers, it will have adverse effects when an error occurs [77]. In the present study, social-political accountability is a form of accountability considered necessary for hospitals. These findings in Gorji's study are also confirmed, emphasizing that even the hospital's clinical performance faces challenges without fulfilling its social and political responsibility [78]. However, studies such as Byrkjeflot recommend that this type of accountability should not limit the accountability of hospitals regarding their clinical performance [79]. Financial accountability improves the hospital's financial status and reduces its costs, and clinical accountability provides high-quality and safe services for consumers. Social and political accountability, in addition to facilitating the hospital's achievement of its goals, can play an essential role in providing political support. and social responsibility of the hospital. When the managers' commitment to accountability is considered as a whole, it can be hoped that the hospital can achieve organizational success and provide sufficient benefits to all stakeholders.

Hospitals are an important part of the health system. If it is a public hospital, it operates as a department under the supervision of the Ministry of Health or regional health organizations. This creates an opportunity for external accountability in the hospital. External accountability can be applied in all financial, clinical, and sociopolitical contexts. However, it probably will not be enough on its own. Public hospitals have a complex internal environment; this environment may cause external organizations to not be able to respond accurately. Therefore, attention should also be paid to internal accountability. Internal accountability requires some authority in the governance structure and makes the hospital's independence necessary in many financial and administrative matters. Many initiatives worldwide have been carried out to reduce hospitals' dependence on the government. Preker divides hospitals into five categories: budgetary, independent, corporate, nonprofit, and private [22]. Similar to the present study, Badr's research also emphasizes that it is necessary to have independence in the hospital's governance structure [80]. The hospital's independence can increase its internal accountability and the governance's ability to exercise authority. By exercising the power of governance, the hospital can take necessary actions in case of deviation from proper performance in the financial, clinical, and social-political fields according to specific regulations.

The accountability plan for the hospital, in which the responsibilities and duties of each person and department are clearly mentioned, prevents confusion in accountability and possible neglect of part of it. Clinicians, doctors and nurses, and society and political officials should clearly understand how the hospital responds and effectively benefits from the hospital's response. Austin argues that having an accountability program and transparent reporting structure will help make hospitals more accountable [43]. Different hospitals need different programs to respond in all dimensions, and these programs cannot be communicated in a single form by a high-ranking institution such as the Ministry of Health. In addition to holding different departments accountable, this program can also help the hospital in terms of execution because the limits of each person's duties and powers are clear in it, and the hospital's governance structure can ask the person or department about the performed functions and ask for a specific answer.

Conclusion

Vast social and economic changes have made health systems inevitably face accountability challenges worldwide. Hospitals are one of the most important entities in the health system and can only continue their practical life with accountability. The accountability of the hospital is primarily related to its governance structure. The current research findings emphasize the four dimensions of responsive governance in the health system. First, the governance structure should be comprehensive and include management, medical, nursing, and community representatives. Second, the governance structure should be open to all types of accountability, including financial, clinical, and social-political accountability. Third, the hospital governance structure should be independent to exercise its sovereignty and power if needed while monitoring accountability. The fourth important issue will be the definition of an accountability plan for the hospital, in which the duties and authority of each department and each person are clear. It is suggested to research the quantitative determination of the impact of each of the themes of the present study on accountability and, ultimately, the quality of health services. Be made. Using the findings of the current research can help hospitals provide their services more responsively and achieve better health outcomes.