Evaluation of hospital accreditation in Tehran: brief report

Hospital accreditation is a systematic external evaluation of a hospital’s structures, processes and results by an independent professional accreditation body using pre-established optimum standards. This study aimed to evaluate the hospital accreditation system.
This descriptive and cross-sectional study was carried out between November 2015 and February 2016 using a questionnaire covering accreditation standards, methods, surveyors, implementation and effects. The study population consisted of 161 hospital managers in Tehran province, Iran. Overall 87 hospital managers were surveyed through stratified random sampling.
The mean score of managers’ satisfaction of hospital accreditation system was 2.93 out of 5 score. About 16 percent of managers were satisfied with the hospital accreditation system. Hospital managers were most satisfied with accreditation effects (3.14) and least satisfied with accreditation standards (2.54). Hospital managers were satisfied with surveyors’ attitude, number of survey days and the number of surveyors in the accreditation team. They were least satisfied with the lack of consistency among surveyors, lack of transparency of standards, too many standards and low competency of surveyors. Hospital managers mostly believed that accreditation should be done by Ministry of Health, compulsory, and every two years. About 97 percent of managers agreed that self-assessment is necessary and beneficial prior to the accreditation survey.
Accreditation was moderately successful in Tehran hospitals. Accreditation had the most effect on improving patient safety and meeting patient's rights and least effect on improving employee's job satisfaction and involving doctors in quality improvement. Strengthening Iran hospital accreditation system, training managers and employees on implementing standards, and providing necessary resources make it possible to achieve accreditation goals.