Abstract
The aim of this research is to design a model for empowering family physicians based on service quality. The present research is developmental in terms of its purpose. The statistical population of the research includes 20 academic experts, policymakers, and family physicians who have complete information about applicable training in the organization. The sampling method is purposive. The data collection tool is a semi-structured interview. The meta-synthesis method was used to analyze the data. Data analysis resulted in the identification of 58 indicators, 11 criteria, and 4 dimensions for empowering family physicians and 32 indicators, 6 criteria, and two dimensions for the dimension of service quality. The model obtained is divided into four themes: required prerequisites (infrastructure, communications, planning); motivational mechanisms (incentives, awareness, power to act); management indicators (evaluation, financial management, and supervision); reforming the service delivery method (training, process improvement) to empower family physicians and the two themes of tangible service quality (diagnostic, cost, and electronic services) and intangible service quality (insurance and accountability, obstetrics and gynecology, and consultation) were approved.
Introduction
The successful implementation of the family medicine program requires understanding its principles and prerequisites. The availability of prerequisites and continuous evaluation of the family medicine program using standard criteria facilitates the achievement of the program's goals. Although the program has had relative success in terms of access to services and comprehensiveness of care, it showed less success in the dimensions of coordination between service delivery levels and continuity of care (Najafi Kersami et al, 2022) and consequently, the growth, progress, development and enhancement of staff capabilities, which has been proposed as "empowerment" in the organization in recent years, is considered one of the effective methods for increasing the skills of staff and making optimal use of their individual and group capacities and capabilities in line with the goals of the organization (Nazifkar et al, 2023). The family medicine program affects the access, quality, efficiency, justice, resilience and sustainability of health services and ultimately, the health of the people and the accountability and financial protection of the primary health care system. The family medicine program has brought many achievements. The successful implementation of this program requires understanding its principles and prerequisites. The availability of prerequisites and continuous evaluation of the family medicine program using standard criteria facilitates the achievement of the program's goals (Mosaddeq Rad et al, 2022). Although the implementation of the family doctor plan is considered a fundamental measure and an important development in the discussion of rural health insurance and the provision of health services and the referral system in the country, evidence indicates that if these challenges and threats are not identified in a timely manner and no intervention is made, only a name may remain of this plan (Mohamadiyan et al, 2018). Service leveling prevents repeated and unnecessary referrals to more specialized levels and prevents waste of material and human resources, and is considered an appropriate tool for controlling the costs of care and increasing alignment between general practitioners and specialists. Ignoring the referral system can break the links in the health and treatment service delivery system, increase costs, and harm the quantity and quality of services. Family physicians should be involved in empowerment and consider all medical, cultural, religious, patient and family status and community status aspects in caring for patients (Jannati et al, 2011).
Considering the above and the importance of implementing the family physician plan, the present study seeks to evaluate this research issue: What is the family physician empowerment model for improving the quality of services in the management of social security treatment in Mazandaran?
Theoretical framework
Empowerment
Empowerment means giving power and helping individuals in the organization to improve their sense of self-confidence, overcome their disability and helplessness, and create enthusiasm for activity in individuals and provide their internal motivation to perform job duties (Golafshani et al, 2022).
Service quality
Service quality is defined as the difference between customers' expectations before using the organization's services and the image they have of the services received. The purpose of service quality perception is the consumer's perception of the services provided by a company. Service quality can be defined as customers' overall attitude or judgment of the services received (Behrozi, 2021).
Endalamaw et al, (2024), in a study titled Review of Continuous Quality Improvement in Healthcare Systems: Conceptualization, Models and Tools, Barriers and Facilitators, concluded that the main reported objectives of using continuous quality, as its positive impact, are to improve the health system structure (e.g., leadership, health workforce, use of health technology, resources and costs), improve the processes and outcomes of healthcare delivery (e.g., care coordination and linkages, satisfaction, access, continuity of care, safety and efficiency), and improve treatment outcomes (reduce morbidity and mortality). Continuous quality implementation is not without challenges. There are cultural (e.g., resistance/reluctance to a quality-focused culture and fear of blame or punishment), technical, structural (related to organizational structure, processes and systems), and strategic (inadequate planning and inappropriate goals) barriers that are commonly reported during continuous quality implementation.
Keelson et al, (2024), in a study titled The Impact of Patient Engagement on Service Quality and Client Well-being: An Introspective Analysis from the Perspective of Healthcare Providers, concluded that it emphasizes the importance of patient engagement in determining healthcare experiences and outcomes, and emphasizes the need for healthcare institutions to adopt patient-centered care principles and foster collaborative and empowering cultures. Based on the findings, patient engagement fosters open communication, shared decision-making, and shared care, all of which are critical components for improving service quality. To improve adherence to treatment, improve health outcomes, and increase patient satisfaction, healthcare providers emphasize the value of giving patients the freedom to actively participate in their healthcare journey. Furthermore, patient engagement has been shown to enhance client well-being by encouraging a sense of empowerment, independence, and control over one’s health.
Research Methodology
The present research is developmental in terms of its purpose. The statistical population of the research includes 20 academic experts, policymakers, and family physicians who have complete information about applicable training in the organization. The sampling method is purposive. The data collection tool is a semi-structured interview.
Research findings
The meta-synthesis method was used to analyze the data. Data analysis resulted in the identification of 58 indicators, 11 criteria, and 4 dimensions for the empowerment of family physicians; and 32 indicators, 6 criteria, and two dimensions for the service quality dimension. The model obtained was approved in four themes of prerequisites (infrastructure, communication, planning); motivational mechanisms (incentives, awareness, power to act); management indicators (evaluation, financial management, and supervision); and reforming the method of providing services (training, process improvement) for the empowerment of family physicians, and two themes of tangible service quality (diagnostic, cost, and electronic services) and intangible service quality (insurance and accountability, obstetrics and gynecology, and consulting).
Conclusion
The present study aimed to design a model of family physician empowerment based on service quality. This finding is consistent with the results of Onog & Bayrami (2023), Matdeen & Sogandi (2022), Eslami (2022), Endalamaw et al, (2024), Keelson et al, (2024), Abbasi & Hajimohammadi (2021), Vafaee-najar et al, (2019), Heydriyan et al, (2022), and Heydarian Nayini et al, (2022). Onog & Bayrami (2023) showed that improving and increasing employee empowerment is possible with transformational leadership of managers, which is consistent with the results of this study. In criticizing the results of their research, it can be stated that one dimension that affects empowerment, namely transformational leadership, is focused on; and other effective variables have not been examined.
According to the results obtained, the following suggestions are made:

It is suggested that the educational curriculum of general practitioners be revised and the approach changed from treatment-oriented to health-oriented.
It is suggested that community-oriented training of general practitioners and empowerment in the context of the community be considered.
Network empowerment is suggested by reviewing the overall structure of the network with the aim of maximally adapting the network structure to the dimensions of non-medical and community-oriented family medicine.
It is suggested that the family physician plan be implemented at the patient's doorstep.