Showing 14 results for Accreditation
F Akbari Haghighi, E Jaafari Pooyan,
Volume 8, Issue 3 (2-2010)
Abstract
Background: Various studies have highlighted the importance of accreditation as a ubiquitous performance measurement system of hospitals. However, the effectiveness of this mechanism has not been addressed, as much it deserves, in developing countries. Therefore, current study intends to investigate the performance of the system using the SERVQUAL model.
Material and Methods: This research is an applied and cross-sectional survey. Decision-making Board of Hamedan Hospitals (N= 200) constitutes the target group. A self-administered questionnaire including both structured and open-ended questions has been used for data collection. Analysis of the quantitative and qualitative data was conducted using SPSS and Thematic Content Analysis (TCA), respectively.
Results: Only 39 percent of the target group had high awareness of current accreditation programme.
The highest rate of gap, 55.8%, between the group's perceptions and expectations from accreditation system, belonged to the indicator of staff's satisfaction and the lowest rate, 17.3%, to structures and establishments.
Conclusion: The low score of the target group's perceptions towards the accreditation programme could be a sign of the low degree of their satisfaction, which might result in their poor cooperation. More and effective attention to hospital managers' views, recommendations and reactions might be an appropriate preventive solution.
J Sadeq Tabrizi, F Gharibi,
Volume 11, Issue 2 (8-2012)
Abstract
Background: Accreditation is one of the evaluation systems which have numerous effects on the key indicators in health care system. To develop a suitable accreditation model, a best way could be the benchmark of the powerful and successful accreditation models in all over the world. By considering likely differences in the various countries health systems, this study aims to survey the compatibility of the best accreditation models and standards in Islamic Republic of Iran's health care system.
Materials & Methods: In this study, the expert's perspectives have been ascertained about standards of selected references accreditation models based on standards "importance" and "feasibility" using two rounds Delphi Technique. The experts selected among scientific and academic experts in the areas of accreditation and health services management. They were asked to fill up the Delphi questionnaire and send back it to the researchers in the designated time. Each standard scored in Likert scale from 1 to 9. Standards with mean score of ≤ 3 were rejected, standards with mean score between 4 and 6 send to the second round and standards with mean score ≥ 7 included in the national model.
Results: In the first round, 20 out of 27 questionnaires have been obtained from experts. After data analyses all the standards have been accepted except 31 with mean score between 4 and 6. Remained 31 standards with achieved mean scores in first round, send back to the study experts through the second round. In the second round, 17 out of 20 questionnaires collected and finally 18 standards were rejected.
Conclusion: According to the variety of standards, comprehensive categories and richness of necessary details of standards, the resulted model in this study could be a rich and suitable model for Islamic Republic of Iran. Therefore, using this model could empower evaluation system and improve the quality of health care system.
M Keshavarz, A Akbari Sari, A Rahimi Foroshani, M Arab,
Volume 13, Issue 1 (6-2014)
Abstract
Abstract
Background: Accreditation is a program that is designed for evaluation of health care organizations and measured processes and structures according to predetermined standards. The purpose of this study is to survey the safety situation and quality of care in selected hospitals of Tehran University of medical sciences based on the Joint Commission International (JCI) standards and determination of their strengths and weaknesses.
Materials and Method: This descriptive, analytical and cross-sectional study was carried out in 5 hospitals. Translated Joint Commission International (JCI) questionnaire checklist with 14 standards was used as the study tool. Data entry and statistical analysis were performed using the SPSS.13 and K Independent Samples tests were used to compare hospitals.
Results: Highest quality and safety of care score belonged to the hospital B (84%) and then to hospitals C (83%), A (72.75%), E (72%) and D (70.5%). Central indices like patient and family rights, quality improvement and patient safety, infection prevention and control standards in the studied hospitals are completely different according to the statistical results.
Conclusion: Study results show that the status of hospitals in terms of safety and quality of care are almost appropriate but in some cases there is a large distance between JCI standards and their current status and the studied hospitals have to make appropriate and related policies in order to plan and implement proper programs to improve their situation in quality and safety of care.
Dr Mohammad Arab, Seyed Masood Mousavi, Dr Aidin Arian Khesal, Dr Ali Akbarisari,
Volume 16, Issue 1 (4-2017)
Abstract
Background: in order to quality improvement, accreditation standards implemented with focus on the clinical and non clinical services. A nationwide intervention such as hospital accreditation can affect on measures related to the provision of high quality services. Indeed, such devices can be considered as effective tools in macroeconomic health sector policymaking. The main objective of current study was to investigate the effect of accreditation system on the key performance indicators of hospitals affiliated to Tehran University of Medical Sciences.
Materials and Methods: The study was a semi-experimental and descriptive-analytical one which conducted longitudinal using an Interrupted Time Series Analysis approach. Data related to the key performance indicators including average long of stay, Caesarean percent, turnover rate, patient satisfaction percent, bed occupancy rate, self-ordered discharge from emergency room and net death rate) was accumulated through multiple visits to the hospitals during 2012-2014. STATA software was used for data analysis.
Results: The study results revealed that based on implementation of accreditation model, the average stay of patients in the hospitals cesarean section rate and turn-over intervals decreased, while the percentage of patient satisfaction and bed occupancy average increased. Moreover, self-ordered discharge from emergency room and average of net death rate indicator showed no change.
Conclusion In general, it can be concluded that the health system partially has achieved a part of their objectives means key performance indicators promotion as a result of hospital accreditation implementation in hospitals affiliated to Tehran University of Medical Sciences. In order to assess more accurate investigation and understanding the nature of the system effectiveness, analysis of different aspects of hospitals performance indicators and the nature of their changes in longer period seems to be helpful.
Dr Alimohammad Mosadeghrad, Erfan Shakibaei,
Volume 16, Issue 3 (11-2017)
Abstract
Background: Accreditation is an appropriate strategy for improving the quality, safety and effectiveness of hospital services. Iran national hospital accreditation was initiated as a government and mandatory program in 2012. This study aimed to identify the prerequisites of hospital accreditation implementation in Tehran province hospitals.
Materials and Methods: This qualitative study was performed using semi-structured interviews with 72 managers in different level from 15 university, private, military, social security and charity hospitals in 2016. Hospitals were selected purposefully through Tehran province hospitals. Content analysis was used in order to data analysis.
Results: Pilot testing of standards before announcing to hospitals for implementation, education and training of hospital managers and employees on accreditation standards, providing required resources, allocating enough time for implementing the standards and providing incentives for implementing standards are the main hospital accreditation prerequisites. Absence of these prerequisites in accreditation implementation resulted in huge challenges for hospital managers and employees.
Conclusion: Providing the accreditation prerequisites for hospitals facilitates implementation of hospital accreditation in hospitals which in turn results in quality improvement, safety and hospital services effectiveness.
Dr Ebrahim Jaafaripooyan, Tahere Sharifi, Dr Sara Emamgholi Poor, Dr Mir Saeed Yekani Nejad, Samaneh Esmaeili,
Volume 17, Issue 2 (9-2018)
Abstract
Background: Hospital accreditation is assumed as an effective control mechanism for health systems to improve quality and efficiency. Current study thus, seeks to look into the relationship between hospitals’ accreditation and efficiency
Materials and Methods: In order to measure efficiency, hospital inputs and outputs included the ratio of physician and nurse to bed, mortality and nosocomial infection rate and quality of inpatientservices were used. A sample of 554 hospitalized patients selected using stratified random sampling
method. Data gathering instruments were researcher-developed questionnaire and checklists. DEAP and SPSS software deployed to assess correlation between accreditation rank and technical efficiency
Results: Average hospitals’ technical efficiency score was 0.94 indicating an improvement capacityof %5.1 for hospitals efficiency. The mean quality score was 4.13 out of 5( in the range of 3.9-4.3)There was no correlation between hospitals accreditation rank and their technical efficiency
Conclusion: According to the results, it seems efficiency should be also considered in accreditationmetrics. In addition, for measuring efficiency, performance based inputs and specifically outputs tohave reliable results should be chosen
Dr Ebrahim Jaafaripouyan, Dr Alimohammad Mosadeghrad, Abbas Salarvand,
Volume 17, Issue 3 (11-2018)
Abstract
Background: Accreditation is one of the health sector evaluation methods that used to promote healthcare quality. The study aimed to identifiy the strength and weakness of accreditation surveyors and the impact of their performances.
Materials and Methods: This study is a qualitative research which conducted between hospital accreditation stakeholders in 2016- 2017. Data were gathered using semi-structured interviews and analyzed by a thematic analysis method.
Results: The findings of in strengthen were categorized in 7 themes. The main strengthen was acceptance of accreditation by surveyors, educational approach, reputation, personal effort to develop knowledge and skills, and existence of senior surveyors. Our results for weakness were classified in 8 themes. The main weaknesses were lack of sufficient knowledge, experience, skills and weakness in personal characteristics. Based on the findings, the accreditation surveyors’ performance was evaluated as under-moderate in past two periods of hospital accreditation. The interviewees announced that weakness of surveyors’ performances was one of the main effective factors of low stability of accreditation results.
Conclusion: Recruitment of surveyors based on main competence, education and empowerment of surveyors, and assessing the surveyors can lead to more validity of accreditation results and finally lead to increasing the commitment of hospitals to quality.
Dr Mohamad Hakkak, Seyed Ali Hozni, Neda Shahsiyah, Tahereh Akhlaghi,
Volume 17, Issue 3 (11-2018)
Abstract
Background: Hospitals are the most important and largest institution in each country's health system which health care services are carried out on a large scale. One of the most important processes to improve the quality of health services is accreditation in the country. This study aimed to identify challenges, obstacles and providing solutions in hospital accreditation.
Materials and Methods: This research is a qualitative one which conducted using content analysis approach in the north of the country in 2017. Twenty-five people consisted of two heads of hospitals, three hospital managers, three matrons, four supervisors, ten nurses, three people responsible for accreditation selected as contributors to the study using a targeted sampling approach. After the interview with Maxqda software, coding was performed and necessary analysis was carried out. In order to obtain data validity, two methods of reviewing the participants and reviewing experts were used.
Results: Analyzed data was categorized in the 98 initial codes, 16 concepts and 5 main categories. The main issues included resource challenges, organizational challenges, technical challenges, negative consequences and solutions.
Conclusion: Pathology helps the organization to focus on problems and by collecting and analyzing data and identifying risky spots, managers and planners will find methods to develop and solve the problem. Particularly, the correct implementation of the accreditation process can lead to comprehensive clinical excellence.
Serajaddin Gray, Saeed Bayyenat,
Volume 19, Issue 4 (12-2020)
Abstract
Background: In Iran, the accreditation system is mainly focused on hospitals and has not yet succeeded in providing standards for independent medical centers such as independent clinics. The present study reports the development of an accreditation framework for independent clinics affiliated with the country's armed forces.
Materials & Methods: This is a mixed (qualitative-quantitative) study. Experts' agreement (30 people) on the results of a systematic review (201 items) was obtained using a questionnaire and through holding three expert panels. The necessity of each item was calculated using the method of content validity ratio and the weight of standards and headings based on the average.
Results: The existing 201 items were converted into 75 standards in 13 headings as final standards with the weight of each item.
Conclusion: This framework can be used as a comparison tool between independent medical centers and it is necessary to train evaluators, and prepare legal and organizational requirements in order to implement it.
Beheshteh Jebelli, Mohammad Varahram, Mehdi Kazempour-Dizaji, Shirin Esmaeili, Habib Emami, Elham Ghazanchaei,
Volume 20, Issue 4 (12-2021)
Abstract
Introduction: After the increase in the incidence and global spread of Covid-19 virus, medical centers faced a number of problems and challenges following this crisis. In order to increase the quality and safety of medical services and their optimal management, both in critical and non-critical situations, health care providers in different countries of the world have used various methods that increase the organizational commitment to improve quality.
Method: This study is a cross-sectional analytical research. Data were collected through a researcher-made questionnaire based on 903 accreditation standards notified by the Ministry of Health by available sampling method from 326 employees of Masih Daneshvari Center in 2021. Data were analyzed using SPSS software version 22.
Results: The results showed that out of an average of 8 areas related to accreditation standards, participants in the areas of professional ethics and compliance with the recipient of services, infection control, environmental health and waste management mentioned the most compliance in the emergency situation caused by Covid-19 and areas of clinical management and patient safety were ranked next.
Discussion and conclusion: According to the participants, observing the areas of environmental health and waste, service recipients and infection control has been more practical during Corona pandemic. The principles of accreditation seem to be accepted as quality improvement standards and can be an effective guide in preparing medical centers for emergency conditions.
Hassan Niroomand Sadabad, Ali Vafaee Najar, Elahe Houshmand, Jamshid Jamali, Zahra Keyvanloo, Mahdi Dehnavi,
Volume 21, Issue 4 (1-2023)
Abstract
Background and purpose: Considering the important role of doctors in the implementation of accreditation standards and the necessity of their involvement in this process, this study was conducted in order to identify the views of doctors regarding the challenges of participating in accreditation programs in social security hospitals in Mashhad.
Materials and methods: This study is a cross-sectional descriptive-analytical research that was conducted in two hospitals of the Social Security Organization of Mashhad, Iran. in 2022. The participants were 56 full-time working doctors with at least one year of work experience in the hospital. Data analysis was done using SPSS version 26 software.
Findings: Among the challenges of doctors' participation in accreditation programs , the dimensions of the motivational mechanism (3.96±0.63) , provision of suitable resources for the implementation of accreditation (3.83±0.78), physician empowerment programs (3.78±0.73) and the role of the quality improvement office in attracting doctors' participation (3.75±0.74) were more important from the doctors' point of view, and patients' demands (2.90±0.75) and role ambiguity 2.77±0.96), were less important in their opinion.
Conclusion: Managers should consider that employee motivation and resource allocation are necessary for the effective implementation of the accreditation standard. Empowering doctors in the implementation of accreditation standards as well as the participation of quality improvement offices to interact with doctors and attract their participation are very important factors.
Seyed Mohammad Mahdi Heydari Baghdadabad, Alireza Maetoofi, Ali Farhadi Mahalli , Mojtaba Tabari,
Volume 23, Issue 2 (8-2024)
Abstract
Background and purpose: Hospitals play a critical role in promoting public health and well-being in social contexts. This necessitates codified standards aimed at maintaining treatment quality and enhancing social satisfaction. Hospital accreditation policy evaluation is considered a systematic process that can have significant social and functional implications for hospitals. This study aims to present an evaluation model of hospital accreditation policy based on the process of paradigmatic phenomenology.
Methods: Using Husserl's (1970) phenomenological approach, this study developed a paradigmatic evaluation model in five analytical steps. First, through interviews with experts and open coding, propositional themes related to the phenomenon under study were identified. A focus group was then formed to discuss and analyze these propositions. Each proposition was scored using the Q-method checklist, with scores ranging from +6 to -6, to identify paradigmatic clusters.
Results: During the qualitative analysis, 16 interviews resulted in 138 open codes. After eliminating redundancies and overlapping codes, 50 propositional themes were finalized. These themes were organized into conceptual clusters within the framework of paradigmatic phenomenology, following Husserl's methodological steps.
Conclusion: The study's findings underscore the formation of a hospital accreditation policy evaluation model structured around causal, intervening, contextual conditions, strategies, and outcomes. This model has the potential to enhance the effectiveness of healthcare service delivery and improve the overall quality of treatment in society.
Ali Ghaffarian, Azam Cheraghi, Masoud Ferdosi,
Volume 23, Issue 2 (8-2024)
Abstract
Background and purpose: Accreditation is one of the most widely recognized and reliable methods for evaluating the quality of hospital services. However, its implementation is often accompanied by various challenges for hospitals. This study aimed to identify the challenges associated with accreditation in small and single-specialty hospitals from the perspective of those involved in the process.
Methods: This qualitative descriptive study was conducted with the participation of 30 individuals, including hospital staff, national accreditation evaluators, and experts from the Ministry of Health's Monitoring and Accreditation Office. Data were collected through semi-structured interviews and individual sessions. Content analysis was used to process the data, which was analyzed using Max-QDA software (version 20).
Results: The accreditation challenges of small hospitals were categorized into four main themes: "accreditation process," "human resources," "structural issues," and "financial constraints." For single-specialty hospitals, challenges were grouped into three themes: "accreditation process," "human resources," and "uniformity of accreditation standards." Common challenges for both hospital types included low staff motivation, insufficient training in accreditation procedures, and issues related to evaluators.
Conclusion: In addition to general accreditation challenges, small and single-specialty hospitals face unique obstacles due to their specific conditions and inherent differences from other hospitals. To ensure the successful implementation of accreditation programs in Iran, policymakers should thoroughly examine the identified challenges and incorporate these insights into national hospital accreditation planning and implementation strategies.
Beheshteh Jebelli, Mohammad Varahram, Fatemeh Keyvani Rad, Solmaz Zarrineh, Elham Ghazanchaei,
Volume 24, Issue 2 (9-2025)
Abstract
Background and purpose: Hekmat (Wisdom) implies deep knowledge, understanding, and sagacity. Hospital services are uniquely dependent on human resources; therefore, beyond technical expertise, staff commitment is essential for maximizing efficiency and effectiveness. A "Hekmat-based hospital" is defined as an institution delivering care founded on three pillars: human dignity, medical knowledge/wisdom, and Islamic ethics. This study aims to identify the key factors influencing hospital accreditation through the lens of the Hekmat-based hospital approach.
Methods: This qualitative study employed conventional content analysis based on the Graneheim and Lundman approach. Data were collected through purposive sampling and semi-structured interviews with 62 participants (32 physicians and 30 patients) from various departments until data saturation was reached. Additionally, a comprehensive review of 20 upstream documents related to health, medicine, education, and culture within the Iranian health system (post-1979 Revolution) was conducted to supplement the field data.
Results: The analysis of interviews yielded 10 main categories representing the components of accreditation in a Hekmat-based context. These categories included: social, cultural, and religious issues; facilities, equipment, and human resources; communication skills; patients' financial and livelihood challenges; knowledge and education; tangible environmental factors; economic factors; cultural dynamics; patients' psychological resilience; and service reliability.
Conclusion: The findings suggest that mutual understanding of emotions and beliefs, patience, reciprocal respect, and effective knowledge exchange are core expectations shared by both physicians and patients. Addressing these primary and secondary needs is a prerequisite for achieving a standardized hospital model aligned with the vision of Hekmat-based medicine.
