Dear editor,

"Quality" plays a very important role in the preservation and survival of health care organizations. The Hospital Accreditation Program in Iran was developed by the Ministry of Health and Medical Education in 2010, and hospitals were accredited based on this program in 2012. The standards of accreditation had been developed in accordance with international standards; however, they were adapted to the conditions of the country. By 2016, hospitals were accredited based on this accreditation program, about which there were a lot of criticisms, because this program overemphasized documentation and hospitals that were able to do the documentation well could receive higher accreditation degrees, although many standards may not be met in practice. The accreditation program also did not involve all occupational groups working in hospitals, especially physicians who did not consider it as a task. In this program, the nurses had been assigned the greatest role. In Iran, most public hospitals use structural indicators such as worn-out buildings, nonstandard manpower, especially physicians and nurses, poor management of hospitals, worn-out equipment, no use of clinical guidelines, overcrowding in health centers, inappropriate payment systems, inappropriate physician and patient relationships, lack of required skills in some physicians and nurses, and inappropriate design of accreditation measures. The results of some studies conducted by independent researchers on the hospital accreditation processes have shown that the actual accreditation degree of hospitals is different from the degree of accreditation awarded to them by the Ministry of Health and Medical Education and there is a significant difference between them, and this indicates that due to the weakness of the structural indicators, the degree awarded does not represent quality in the real sense.1-5

In response to these issues, the Ministry of Health and Medical Education issued a new edition of the accreditation standards to the medical universities in mid-2016. In the new edition, unnecessary documentation has been removed because the previous version involved the hospital staff, especially the nurses, too much in documentation. In the previous version, the volume of standards was very high, but in the new revision, the volume of these standards has been greatly reduced, and more emphasis has been placed on the essential and vital standards. In the previous edition, standards were sector-based, but in the new edition, efforts have been made to focus on the task orientation standards and standards related to the role of service providers as a substitute for the sector-based standards. One of the major strengths in the new edition is to strengthen teamwork, instead of individual work, to continuously improve services. Empowering employees through continuing education based on needs assessment, enhancing employee motivation through linking payment systems to service quality, emphasizing the patient safety, and fulfilling the international requirements are remarkable points in the new revision of the accreditation program in Iran. However, accreditation is subject to the rules that should be observed when executing this program.

In the new accreditation program, there are several challenges: hospitals do not have enough time to adapt to these standards, which is unlike what is happening around the world; the employee empowerment methods are not functional and do not have the required effectiveness; the accreditation is not performed by an independent organization but by the Ministry of Health and Medical Education staff themselves, who have conflicts of interest; the evaluators and assessors do not have the necessary knowledge to assess the hospital services because they have not completed the professional assessment courses; the removal of the independent dimension of patient safety and the integration of its measures into other dimensions, turning some measures into executive steps; and its highly ambiguous scoring and weighing system.3,6

Therefore, the following suggestions can be made, that: the accreditation process is carried out by an independent and nongovernmental organization; like the latest edition of the International Accreditation Standards, in which the first standard is related to the International Standard for Patient Safety, the patient safety is considered as an independent dimension; in the formulation of accreditation indicators, a combination of structural, process, and operational indicators is taken into account; accreditation is carried out by professional accreditors who had a high level of knowledge, experience, and skills, as well as valid certificates; giving enough time to the medical centers to comply with the standards because changing the attitude of employees and organizational culture, providing continuous training, monitoring, and continuous improvement in the programs and process objectives are time-consuming and require at least 3 to 5 years. If such suggestions are accepted and followed, the opportunities for international accreditation and improved service quality will be provided.

-Mohammadkarim Bahadori, PhD

Health Management Research Center, Baqiyatallah

University of Medical Sciences, Tehran, Iran

[email protected]

-Ramin Ravangard, PhD

Health Human Resources Research Center, School of

Management and Information Sciences, Shiraz University

of Medical Sciences, Shiraz, Iran

-Mahnaz Mayelafshar, MSc

Department of Health Services Administration, Tehran

Science and Research Branch, Islamic Azad University,

Tehran, Iran

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