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Volume 1, 2016, Issue 2, Pages 50-56; Paper doi: 10.15412/J.JCC.02010203; Paper ID: 20016.
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Explaining the Views of Managers of Departments and Units of Farabi Hospital in Mashhad on the Implementation of Accreditation Standards in the Hospital
(Research Paper)
  • 1 Department of nursing, School of nursing & midwifery, Research Center for nursing & midwifery Care, Shahid Sadoughi University of Medical Science, Yazd, Iran
  • 2 Health Technology Assessment, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
  • Correspondence should be addressed to Aliakbar Vaezi, Department of nursing, School of nursing & midwifery, Research Center for nursing & midwifery Care, Shahid Sadoughi University of Medical Science, Yazd, Iran; Tel: ; Fax: ; Email:


Throughout the world, people, patients, the government and third-party payers demand better assessment of health services conditions for continuous improvement of quality. Accreditation, due to maximum and challenging standards, is considered as the most powerful method in this domain. Therefore, the aim of the present study is explaining the views of authorities in Farabi Hospital in Mashhad on the implementation of accreditation standards. this study was conducted using content analysis method in the summer 2014. The sampling was purposeful and the data collection was done using semi-structured interview with the authorities of Farabi Hospital in Mashhad and then the contents were transcribed and data analysis was done using Landman and Grantham’s method. 3 categories, 11 subcategories and 64 main codes were extracted based on the analysis of the findings. The first category was: understanding the necessity of accreditation with subcategories: the reasons for accreditation, positive beliefs on accreditation and its outcomes; the second category was: the obstacles of accreditation having subcategories of negative beliefs on the determined standards, inadequate motivation, inadequate education, lack of clarity of methods and programs and infrastructure shortage; and the third category was: the strategies for the improvement of accreditation implementation with subcategories: the correction of infrastructures, creation of motivation in the personnel, operational planning and monitoring. The necessity of accreditation for maintaining and improving service quality is understood by the managers of the hospital units and the obstacles of its implementation can be tackled by appropriate operational program. Of course, considering the strategies identified for the improvement of the implementation of accreditation, the executive prerequisites such as infrastructure correction, creation of positive perspective and adequate motivation in personnel and necessary holding educational courses should be provided.


Hospital Accreditation, Managers, Qualitative Study, Standards


ithout doubt, nowadays appraisal is one of the main, most extensive and controversial management topics (1). The lack of appraisal in different aspects of the organization such as the use of resources, human resources, objectives and strategies is considered as one of the signs of organizational dysfunction (2). Growth, development and improvement in any system including the health system is not possible without effective and appropriate appraisal (3). The health system, despite the significant advancements in science and technology and the creation of big and equipped health centers, has always faced challenges (4). The lack of an effective appraisal system for hospitals results in low-quality services and risk for patients’ rights and society’s health (5). Accreditation is a type of appraisal for hospitals that emphasizes the implementation of predetermined standards (6). Accreditation is a criterion for assessing the extent to which hospitals follow these standards (7). From 1950s to the early 1990s, the accreditation programs existed only in developed countries. However, the increase of the need for the qualitative improvement of health services and the increasing statistics of medical errors resulted in the significant increase of them in recent years in a way that the programs were also implemented in developing countries in 1990s. And nearly 60 countries were implementing or doing the processes for the creation of national healthcare accreditation programs by the year 2004.

The appraisal of medical institutions in Iran can be examined in four periods (8):

  • The first period is related to before the Islamic revolution, in the years 1967 and 1968, in which the appraisal was a translation of a foreign standard and was focused on the services by nurses.
  • The second period of appraisal was related to the years 1984 and 1985 and this yearly appraisal considered a hospital with an overall score lower than 20 to be below the standard.
  • The third appraisal period in Iran is related to the years 1996 and 1997 and the appraisal was designed for public hospitals and had at least four main sections with separate forms for assessment of emergency unit and other sections of the hospitals. Some qualitative indices were added to this program in 2003.
  • The replacement of previous assessment with an accreditation that began since 2013.

Accreditation means systematic assessment of the centers that provide health services by specific standards; the standards that emphasize the existence of strategic programs, human resource empowerment, determining work methods and policies, continuous quality improvement, centrality of the patient and the improvement of patients’ and employees’ safety. Few studies have been conducted on the effects of accreditation on providing health services (9). The studies by Salmon et al (2003), Rene et al (2006) and Greenfield et al (2008) indicated that accreditation is a process that leads to performance improvement and positive medical outcomes for patients (10, 17). In a study by Pomey et al it was believed that accreditation, due to the lack of attention to the daily activities, results in fatigue and lack of attention to daily working activities (17). In a study by Karimi et al (2011), the positive impacts of accreditation from the perspective of scholars have been explored (18). However, no study has been conducted in Iran based on the perspectives of individuals directly involved and the implementers of the accreditation standard enacted by the Ministry of Ministry of Health and Medical Education. Therefore, the present study aims to explore the views and experiences of the authorities of a hospital on the accreditation standards after one year of implementation of accreditation.


This study is a qualitative study of content analysis type. Qualitative content analysis can be considered as a research method for subjective content interpretation of textual data through systematic classification processes, coding and theme creation. In addition, a fundamental characteristic of qualitative studies is theorization rather than testing a theory (19). This study was conducted in 270-bed Farabi Hospital in Mashhad which belongs to Social Security Organization in 2014 and the sampling was purposeful. Streubert believes that in purposeful sampling the explored individuals are selected based on the aim of the study rather than random methods. In designing the study, the interview was conducted with the authorities of different parts of the hospital including nurses and the authorities of paraclinical, financial and support units. After the initial interview, transcription, the initial analysis and code extraction, other studies were conducted based on the data obtained and finally, 19 of the aforementioned authorities were interviewed to reach data saturation. This means that no new data was obtained with the next interviews. The interviews were individual, semi-structured, in the participants’ workplace and at an agreed time. Each interview lasted 25 to 45 minutes and the data were collected through phone call in the cases that required reinter view. The interview questions were controlled and verified by two professors. The interview questions revolved around the following cases:

  • How much is accreditation necessary for hospitals and the health system?
  • How much is your knowledge of accreditation and how did you became familiarized with accreditation?
  • What are the main problems facing you for the implementation of accreditation standards?
  • How much do the standards have impacted the performance quality and providing services in your unit?
  • What strategies or recommendations do you have for better implementation of standards?

The data analysis was done based on Landman and Grantham’s method. The following 5 stages were followed for data analysis in this method:

  • Word by word transcription of the interviews and examining them several times for obtaining their overall sense
  • Dividing the text into summarized units of meaning
  • Abstraction of the summarized units of meaning and tagging them by codes
  • Breaking down the codes into subthemes by comparing them based on their similarities and differences
  • Adjusting the themes as the indicators of the text’s hidden content

All the participants had a history of responsibility before accreditation implementation and they were familiar with it. The topic and objectives of the study were explained to the participants and they were assured regarding the confidentiality of the individual interview for observing the ethical issues in each interview. The interviews were recorded from the beginning. The data analysis was done after transcription. The interviews began after obtaining the participants’ consent and recording the information. After transcription of the interview, the data analysis was done and the participants saw it and verification was obtained from them regarding the content. No new information was obtained in the last few interviews and, considering the repetition of the topics mentions, the researcher found that data collection had reached a saturated level and it was ended with 19 interviews. The content of each interview was examined and summarizes for data analysis. Then the reduction and coding the data resulted from the interview were done and revised to obtain a good structure. In order to achieve accuracy and trustworthiness in the study the criteria provided by Lincoln and Guba i.e. credibility, transferability, dependability and confirmability were considered. Therefore, the present study was conducted with emphasis on selection of appropriate framework, information resources and participants in interpretation, adoption of team approach using collective views of the research team and other colleagues, revisiting the participants and more clear determination of stages and processes for facilitating the exploration and its understanding by others to ensure the trustworthiness of the study.


Out of the 19 participants, 10 (53%) were female and 9 (47%) were male. One individual (5%) had a history of more than 1 year of responsibility and most individuals (95%) had a history of more than 3 years of responsibility.

155 initial codes were resulted in the data analysis and, finally, by merging similar codes based on similarities and differences, 64 main codes, 11 subcategories and 3 categories including: understanding the necessity of accreditation, the obstacles for the implementation of accreditation and the strategies for the improvement of accreditation implementation were obtained (Table 1 ). Conventional content analysis that is designed for analysis of qualitative data was used for data analysis (20). In results, the word “P” with the number represents the participant.

Table 1. Codes, categories, and subcategories

Category: understanding the necessity of accreditation

According to the results of the interview the participants believe that any system, for ensuring the correctness of processes and their adaptation with regulations, needs a monitoring and a supervision that consider the quality of services, patient safety, personnel empowerment, appropriate responsibility and patient satisfaction. For example, the participants noted that: “there is a need for accreditation to guarantee quality and to ensure the adaptation of the processes with the regulations” (P15); “accreditation has resulted in the increase of quality” (P4); “it eliminate personal preference in factor of fixed procedures and scientific and experts’ views to some extent” (P8); “accreditation is important to insurance of organizations and the visitors” (P9); “accreditation makes hospitals pay attention to planning and correction of work processes and workflow is done based on standards” (P2).

Topic 2: the way of being familiarized with and informed of the provisions of accreditation standards

The authorities’ knowledge and awareness of the concepts and principles of accreditation standards have a significant role in the implementation of accreditation and the transfer of information to other personnel. It seems that education in this regard has not been enough, according to the authorities’ views, in a way that the participants pointed out that: “I have no knowledge of it” (P2); I have a relative knowledge mostly obtained by studying book of standards and measures and checklists” (P9)”; “some categories were useful but not adequate” (P3) and “there are still many ambiguities and it is not known from who and where we should ask about them” (P7).

Topic 3: understanding accreditation

Understanding the concept of accreditation correctly can help in acceptance and creation of motivation for activity and pave the way for its implementation. It is obvious that the lack of a correct and positive understanding of accreditation is a big obstacles for correct implementation of accreditation. In this regard, the participants said: “accreditation has many unnecessary documentations and is focused on documentation” (P7); “it will mostly lead to affectation” (P13); “there is no attention to some important clinical issues that have a significant role in service quality in accreditation measures” (P10). On the other hand, some participants believed that “accreditation determines work standards” (P8); “it pays attention to qualitative issues and results in the increase of service quality” (P9) and “it is a systematic and purposeful tool for achieving a level of favorable service” (P4).

Topic 4: belief on the determined standards

The views of the interviewees regarding the announced standards were asks and they noted that: “the determined standards are not applied and do not help in the improvement of activities much; for example, a big part of the personnel file is collection of documents that exist in the administrative section” (P4); some cases are continuously repeated while do not have much value” (P6); “some standards have ambiguities and complexities in a way that they are interpreted differently by different individuals” (P8); “some standards are not compatible with our organizational culture” (P14); “the implementation of some standards is highly time consuming while these standards have a low score” (P9) “the score of the standards are not based on their importance” (P15). On the other hand, some participants believed that “standards are acceptable” (P11) and “though they have advantages and disadvantages, they are better than the previous evaluation” (P13).

Topic 5: problems facing accreditation implementation

Regardless of the way the accreditation standards are, the implementation of accreditation faces some obstacles and problems sometimes. The participants believed that the lack of attention to the personnel’s motivation, inadequate and ineffective education, the lack of participation of all personnel and negative experiences have resulted in the creation of some obstacles in appropriate implementation of accreditation. Some of their words are as follows: “considering the negative experience of the implementation of quality management systems, no appropriate culture construction has been done for the implementation of accreditation” (P8) and “mental and practical preparedness have not been achieved in personnel” (P7) in a way that “most employees do not have enough motivation for cooperating in accreditation implementation”; “the education has not been enough and it has not been adequately effective because it has not been continuous” (P10); “in some cases, there has been no agreement among the teachers which in turn results in the lack of enough attention by the personnel” (P7); “ some educational courses have been repetitive and unapplied” (P3) and “some documentations and cases are prepared with uncertainty and trial and error” (p14). The managers’ role in its implementation was one of the points paid attention to by the participants: “the lack of senior managers’ internal belief and commitment is apparent from their performance” (P70); “some authorities do not have enough mastery” (P5); “the lack of clear and timely notification on the programs and objectives make the personnel not pay necessary attention” (P11); “the implementation and follow-up to the implementation are usually ignored and the units are under pressure for doing works near the time of assessment and this results in superficial doing of works” (P13); “the shortage of human resource in some sections results in the creation of opportunities for doing accreditation demands” (P10); “some employees, and especially doctors, have not participated in the accreditation” (p14); “no significant distinction in terms of reward and punishment between the individuals who have participated and those who have not” (P16); “there is the lack of a reference for resolving the ambiguities and the office for the improvement of quality itself has inconsistencies” (P7); “the multitude of documentations and their time demand result in the lack of enough attention in implementation” (P9) and “the use of personal preferences by the assessors during the accreditation results in the lack of obtaining score despite doing the necessary actions” (P4).

Topic 6: the outcomes of accreditation implementation

Despite some criticisms of some aspects of accreditation, all the participants acknowledge that, if accreditation is implemented correctly, there will be advantages of it including:

“It results in the uniformity of procedure in doing works in medical centers” (p7); “the processes and works and their legal regulations are determined and documented” (P14); “employees will participate more in determining work processes” (P9); “the patients’ and personnel’s safety is more paid attention to” (P7); “it results in continuous service improvement” (P1); “it has a significant role in providing a responsible-centered system”; “it pays more attention to experts’ views and knowledge in activities” (P8) and finally, “it will result in more attention to the patients’ and visitors’ satisfaction” (P3).

Topic 7: strategies and recommendations for better implementation:

Based on the participants’ views it seems that senior managers should pay more attention to the formulation of executive programs and provision of the necessary infrastructures:

“The existing conditions should be identified and measured in the first step” (P9); “the change from traditional to scientific management should be done gradually and with a cohesive and continuous program” (P15); “the duties of each unit should be broken down, the time of each activities should be specified and the control should be done at the determined times” (P11); “senior managers should have a firm belief in accreditation” (P4); “senior managers should show the importance of accreditation in their words, behaviors and performance” (P8); “the managers should have enough mastery of accreditation topics” (P14); “the personnel’s and authorities’ negative beliefs should be changed first” (P2); “the interested, active and able individuals should be identified and optimally employed” (P1); “the feedback of activities, especially the positive impacts of accreditation, should be given to the personnel in addition to the regular monitoring and control of activities” (p7); “the determined objective should be explained to the personnel” (P5); “personnel should be used in decision-making and determining the objectives” (p3); “due to the personnel’s and especially managers’ busyness, it is better to allocate specific time for managers to do activities in the domain of accreditation in a group form”; “due to personnel’s tiredness of implementation of ISO, clinical governance and IMS systems and the lack of tangible positive effects, it is better to first create positive mentality and enough motivation in personnel” (P7); “there is a need for funding and enough budget for better implementation of many aspects” (p9); “many important executive policies and methods are better to be designed by the Ministry of Health and Medical Education and be announced to the hospitals for implementation” (P12); “there is a need for appropriate educational pamphlets and booklets for different topics so that personal interpretations are not made” (P14); “new information sharing technologies and information technologies can be used for notification, education and organization of necessary information and even monitoring and supervision” (P. 15); “the independence of the organizations that do the assessments has a significant role in creating enough motivation in personnel and authorities” (P. 4) and “continuous implementation is important rather than abandoning the system and doing things hastily near the time of the assessment” (P13). This study specifies a framework for the identification and understanding of the factors that impact the implementation of accreditation in hospital. The aim of this study was identifying and understanding the views of authorities on the implementation of accreditation so that the results can be used for a more appropriate planning of accreditation standards. The results of this study were categorized into three main categories: the necessity of accreditation, understanding accreditation and the strategies for better implementation of accreditation. This study found that the existence and implementation of accreditation systems are necessary for hospitals. However, there are some criticisms of the existing accreditation standards and as accreditation has started in Iran recently, it should be reviewed and this study can help in this regard. Most authorities believed in the existence and necessity of accreditation and considered it as a factor for maintaining, ensuring and improving service quality and these results are similar to the results of the similar studies conducted in other countries such as the studies by Salmon et al (2003) and Rene et al (2006) which showed that accreditation had positive outcomes for patients’ treatment (10, 17). Regarding the introducing accreditation and teaching the standards, there is a need for more attention as most authorities considered the trainings as inadequate or ineffective. Too much documentation in hospital accreditation in a short period of time has resulted in the feeling of tiredness and boredom with the volume of the documentation in some individuals and they have considered these documentations as unnecessary. This is also pointed out by Pomey et al (17). Maybe such opinions would have been few, if the accreditation parts were announced gradually with each part being announced after documentation. The high amount of documentation has resulted in more focuses on its preparation and less attention to implementation. This indicates the necessity of paying attention to the compatibility of performance with documentations. The lack of independence of accreditation institutions and the standards being notified have resulted in the lack of enough knowledge and accuracy in the assessors (21, 22). In this study too, it was revealed that the lack of a valid reference for determining issues and the use of personal preferences by the assessors resulted in ambiguity in the executive performance of accreditation. Finally, for proper implementation of accreditation, the participants believed that adequate motivation should be created in the personnel first. Appropriate education also should be provided regarding the way of documentation and implementation of the standards and, together with education, formulated, clear, continuous and gradual programs should be created for step-by-step implementation of the formulated standards. Of course, appropriate infrastructures such as information management technological systems, enough human resource and credit have a significant role in this regard.


The present study indicated that in order to ensure the appropriate implementation of accreditation in hospitals, it is better to create uniformity of procedure regarding some guidelines, policies and executive methods that are common in all conditions using the standards created and announce by the Ministry of Health and Medical Education. The value and scores of the measures should be proportionate to the importance of the subject. The documentations should be reduced as much as possible and focus should be on the assessment of performance and clinical services. And the assessment should be done by an independent institution so that the feeling of bias is not created in the assessment for hospitals. Also, senior managers in hospitals should pay attention to culture construction and creation of positive motivation in personnel. Appropriate planning based on the assessment of the existing conditions for step-by-step implementation of accreditation together with appropriate and adequate notification and education lead to the clarity of the way of implementation for personnel. Considering the high volume of documentation and the necessity of continuous remembering and easy and fast access, the appropriate use of information technology and appropriate software can be helpful.

Not mentioned any funding/ support by authors.


The researcher appreciates the cooperation of all those who participated in this study, the authorities at Farabi Hospital who paved the way for this qualitative study and all those experts who were the guide to conducting this study in a better way.


This work was carried out in collaboration among all



The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this paper.


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Paper Title: Explaining the Views of Managers of Departments and Units of Farabi Hospital in Mashhad on the Implementation of Accreditation Standards in the Hospital
Paper Details: Volume 1, Issue 2, Pages: 50-56
Paper doi:10.15412/J.JCC.02010203
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