Evidence Based Health Policy,

Today, health care managers need to manage their organizations with more change than ever before and notice that the changes and the pace of change have also increased. Changes are fast, complicated, confusing, and unpredictable. Health care managers must not only adapt their organization to changes but also lead their organizations to take advantage of the opportunities created and at the same time stay away from external threats and re-engineer business processes to ensure efficiency, effectiveness, and ultimately success (1-4). Health service providers face challenges related to two major issues, difficulty to satisfy patients and the need to change the internal organization to adapt to technology and procedure changes (5).
In such changing situations, managers need tools and techniques to respond appropriately to unpredictable events and be able to survive in a competitive atmosphere (6). One of the effective strategies for organizations' successful and the most common managerial practice in healthcare providers is running strategic plans (7). In the current competitive environment, strategic management is a field that has been considered among other areas of management since the emphasis in this area enables organizations that by focusing on the most important actions, guarantee their long-term viability and success(8, 9). Strategic management is one of the concepts and tools that managers and experts have accepted in different countries by emphasizing the organization's interactions and the environment and establishing a proper relationship between them(10, 11). Environmental changes and competitive pressure, which have forced business organizations to use strategic management, are also included in healthcare organizations because health care is a complex business that uses common processes adapted with more complex commercial companies. A point to be considered, which refers to strategic management in hospitals, reflects the strategic planning in these organizations (10).
In developing countries, health systems are faced with resource constraints, complexity, and economic and political fluctuations (12), and so under the turbulent and complex conditions, strategic tools are needed to achieve higher levels of performance. (13) Strategic planning can be defined as a set of theories and frameworks which, along with complementary tools and techniques to assist managers in thinking, planning, and designed strategies (14, 15). The purpose of the strategic planning process is to develop appropriate strategies for moving the organization forward. The importance of correctly defining the strategies arises firstly, no organization has unlimited resources, and secondly, with the implementation of a wrong strategy, the organization faces many challenges (16).
Since 2010, the Iran  Ministry of Health and Medical Education (MOHME) has implemented a hospital accreditation system to oblige hospitals to have a strategic plan to improve hospital services' performance and quality (17). According to Sadeghifar study the studies hospitals formulate a strategic plan as a necessity for MOHME, but the strategic management process in these centers has not been implemented. (17) although most hospitals in Iran today have documented strategic plans (18), the question of whether their activities are consistent with the program is a negative one. In other words, there are many differences between the strategic plan and what is happening in the hospitals of Iran. Undoubtedly, many requirements and conditions need to be considered in the design and implement an appropriate strategic plan for the organization, and no matter what, you cannot expect the program to have the desired result) 17, 19). Many issues need to be addressed in developing a strategic plan; one of the most important the effective participation of various stakeholders in developing a strategic plan. There are different opinions about who exactly the stakeholders are. Many recent definitions of stakeholders build on Freeman's researches about stakeholder theory. Accordingly, stakeholders include any individual or group who can affect or be affected by the organization's objective (20). Stakeholder analysis is defined as a process for defining components of social and natural phenomena that are influenced by decisions or actions and identifying individuals, groups, and organizations affected by or may affect parts of the phenomenon;  through this analysis, conflicts between stakeholders are identified, and it is ensured that these conflicts are not exacerbated by subsequent activities (21). Stakeholder participation is essential and even vital to the transfer of knowledge into action in health care.
When health care professionals are involved, efforts to transform large systems are more successful, resulting in improved clinical outcomes and patient safety, quality of care, and financial performance (22). According to what has been stated, this study aims to answer the extent to which the hospitals in the development of their strategic plan consider the stakeholders and how the participation of stakeholders in the development of the strategic plan was. Also in this study, consideration of the components of the strategic plan (including vision, mission, internal and external factors, etc.) in hospitals has been investigated.
Materials and Methods
This cross-sectional, descriptive study was performed in the teaching hospitals of Tehran University of Medical Sciences (TUMS) and Iran University of Medical Sciences (IUMS) in Tehran city (N = 27). It should be noted that TUMS has 17 hospitals, and IUMS has ten hospitals that provide specialized and super-specialized services. Three hospitals refused to be involved in the study, and this study was conducted among 24 hospitals. Of these, eight were general hospitals and 16 special hospitals. The study population included all Strategic Planning Committee (SPC) heads and key informants in strategic planning in the studied hospitals.
The data gathering tool was a  researcher made questionnaire developed from literature review (23, 24)  and expert comments. The questionnaire consists of three parts. The first section includes items about the demographic variable (including hospital specialty, number of beds, number of staff, age of hospital, accreditation grade, and education degree of hospital managers). The second section included questions about the involvement of various stakeholders (including the head of the hospital, manager of  hospital, assistants, and nursing manager, head of clinical department, head of the supportive sections, staff at operational levels and other stakeholders such as representatives of patient/donor, representative of university in the strategic planning process is in five domains including participation in meetings, provision of the required information, provision of initial ideas, provision reformed and completive suggestions for plan formulation, presentation of gathering and documentation of plan. The third part of the questionnaire included 15 questions about the amount of attention to important dimension of strategic planning.  The 5 degree Likert scale and triple range from weak (0-2.50) to moderate (2.51-4) and good (4.01-5) were used to analyze.
Five experts in strategic planning confirmed content and form validity. To check the tool's reliability, we selected 5 of the key people with the greatest awareness of the strategic plan from five hospitals and, through simple random sampling and ran a pilot study in them. Cronbach's alpha (α = 0.8) confirmed the questionnaire's reliability.
The questionnaire was completed by the investigator in the form of an interview. In each hospital, the key person/persons with the greatest awareness of the strategic plan were interviewed. Job-status of persons that participated in this study in the studied hospitals included  manager  of quality improvement (13 hospitals), expert of hospital affairs (4 hospitals), head of clinical governance (2 hospitals), manager of hospital, Research and Development executive (R&D), clinical supervisor, and  head of systems and procedures. The objectives of study were explained to the participants, and to confirm the accuracy of answers, the available documents in the hospitals were also studied if further review required.
Data analysis was conducted with SPSS₁₈. Descriptive statistics (means, standard deviations, and percentages) were calculated.
This study's ethical approval was obtained from the Ethics Committee of IUMS (Approval Number/IUMS/SHMIS-2012/527). The main ethical issue was respondents' right to anonymity and confidentiality. The questionnaires were distributed among participants with a participant information sheet describing the objectives of study. The informed consent was taken verbally from the respondents. The questionnaire data were kept confidential, and the respondents were assured of their right to withdraw at any time. The names of respondents were not recorded; thus, the data were rendered anonymously.
Results
All of the studied hospitals as national referral hospitals providing medical and educational services. More than two-thirds of these hospitals were specialized, and most of them had one accreditation degree. Most of these hospitals were established over 30 years ago, that half of them had more than 200 active beds, and about one-third had more than 500 employees. Also, most of managers of hospitals   had a Master's Degree in health service administration (Table 1).
The results of the stakeholder participation in the process of strategic plan development, including participation in meetings, provision of the required information, provision of initial ideas, provision reformed and completive suggestions for plan development, and presentation of gathering and documentation of plan is as follows:
Most stakeholder involvement in the provision

of the required information (42.9 percent), participation in meetings (42.3 percent), and provision reformed and completive suggestions for plan development respectively, and presentation of gathering and documentation is the lowest (34.7 percent) (Table 2).
Various stakeholders have different participation in the process of developing a strategic plan. Based on results, hospital managers (91.0 percent) and assistant and nursing managers (84.2percent) had the highest participation level in the process of formulating a plan. About half of the hospital heads, officials of the clinical and supportive sections participations was moderate to low.
Participation of external stakeholders, such
as representatives of patient/ donor and representative of the university, was very weak and less than 10 %. (Table 3)
Another component examined in this study attention was paid to the different components and steps of developing strategic planning illustrated in Table 4. With a mean score of 62.7percent, this component indicates the average level regarding strategic planning components and stages in the studied hospitals.
Parts of the strategic plan addressed in
most studied hospitals included vision formulation, mission review, evaluation of strengths, weaknesses, opportunities, and threats, determining long-term and short-term goals, and formulation of the operational plan. The least attention is devoted to evaluating the proposed strategies' feasibility, identifying competitive and strategic differentiation, and identifying stakeholders' concerns and needs, respectively.

Table 1. Hospitals demographic characteristic

Demographic features		Number	Percent
Type of hospital	General	7	29.2
	Specialty	17	70.8
Active beds	< 200	12	50.0
	201 -500	10	41.7
	500 <	2	8.3
Accreditation grade	1	6	25.0
	1 +	18	75.0
Age of hospital	< 30	2	8.3
	31 -50	9	37.5
	50 <	13	54.2
Employee number	500  >	15	62.5
	501 <	9	37.5
Field of study for hospital manager	Health care administration	14	58.3
	Other	10	41.7
Education level for hospital manager	Bachelor	2	8.3
	Master	11	45.8
	Medical doctor	4	16.7
	PhD	7	29.2

Table 2. The participation status of various stakeholders in developing the strategic plan

Stakeholders involvement domains	Participation  stakeholders
	Low	Medium	High
Attendance at meetings	43.8	13.9	42.3
Providing needed information	44.6	12.5	42.9
Providing initial ideas	46.8	13.0	40.2
Providing corrective and supplementary suggestions in the formulation of the strategic plan	47.2	15.3	37.5
Presenting conclusions and writing the strategic plan document	51.4	13.9	34.7

Table 3. Various stakeholders' involvement in developing the strategic plan

Stakeholders	Low	Medium	High
Hospital heads	30.0	16.7	53.3
Hospital managers	3.2	5.8	91.0
Head  of Nursing Services	7.5	8.3	84.2
Clinical department head's	22.5	25.0	52.5
Support department head's	19.1	25.0	55.8
The lower level employee	66.6	25.0	8.4
External stakeholders	93.3	5.0	1.7
Patient representative/charity	92.6	4.2	3.2
University representative	87.5	8.3	4.2