Comments on "Iran Hospital Accreditation System".

Dear Editor-in-Chief

A paper entitled “The Accreditation of Hospitals in Iran” was published in Iranian Journal of Public Health, Vol. 44, No.2, Feb 2015. The paper lacks reliable, credible and trusted evidences to support the claims that the authors made. For instance, the authors claimed, “In Iran, at first, the hospital accreditation system had only focused on the structural standards and it was a lot of criticism.” No evidences for such a claim have been provided. The authors also wrote, “The hospital accreditation system in Iran emphasises too much on documentation. As a result, the link between the hospitals’ accreditation degrees and the quality of their services is missing”. The sources for such a strong claim (i.e., 6, 8, and 9) are researches conducted in Korea and Kenya. The same can be seen in other sections of the paper. It is mentioned that “Iran national hospital accreditation standards derived from the standards of the JCI” and the reference for this claim (i.e., 6) is about Korea’s healthcare accreditation system. The authors did not provide sources for their claims in some other sections. For instance, they mentioned, “The accreditation organizations and bodies in India, Indonesia and Malaysia are independent entities; in Ghana, Nigeria and the Philippines are part of the National Health Insurance Program; and in countries such as Mali and Vietnam are similar to those in Iran.” These sharp criticisms without reliable and credible evidences mislead the international audiences of the journal.

Accreditation of a health care organization is an external evaluation of the level of compliance against a set of standards (1). The accreditation process covers all areas of the healthcare organization’s operation and practice. It aims to ensure that the healthcare organizations address the quality and safety of patient care. The objectives of a hospital accreditation system are to assess quality and safety of care; to provide external recognition of the quality of care; and finally to improve public confidence in healthcare services provided by hospitals. An accreditation program is an effective strategy for improving the quality of care (2–4) and patient safety (5) and results in better organizational performance (6–7).

There is no visible pattern towards the governmental, non-governmental, mandatory, or voluntary status of the hospital accreditation programmes. However, there is a clear trend of increasing government involvement in the hospital accreditation programmes (8). For example, although hospital accreditation is voluntary in US, it is a requirement for hospitals to have accreditation to become providers in the Medicare programme (9). In France, accreditation is governmental and has been compulsory since 1996 (10).

Iran’s national hospital accreditation standards are not a translation of the JCI standards. The US (JCAH), Canada (CCHSA) and Australia (ACHS) have launched their hospital accreditation systems in 1951, 1958 and 1973 respectively (8). Many countries’ hospital accreditation systems were influenced by the United States, Canada and Australia accreditation standards. For instance, German’s hospital accreditation system is influenced mainly by US, Canada and Australia. Ireland influenced mainly by Canadian hospital accreditation system. Italy was influenced by ISO standards and Scotland influenced by EFQM (8).

For developing Iran’s national hospital accreditation standards, a literature review was conducted and the hospital standards of countries such as US, Canada, Australia, France, Lebanon and Egypt were reviewed. Particular attention was paid to those countries, which had the most developed hospital accreditation systems. Following the literature analysis, surveys were conducted to decide areas to be covered. Focus group discussions were also held with hospital managers, academic scholars and accreditation experts to develop and customise Iran hospital accreditation standards. The standards manual was drafted in distinct “departments” format including over 8000 standards (11). The standards were judged relevant and then were edited. Therefore, one can see that it is not a translation of the JCI standards, which is in “functions” format (12).

The hospital accreditation procedure was tested using the first draft of the standards in 2011. This pilot testing was carried out in 8 volunteer hospitals, representing different types of hospitals in Iran. During this phase, comments and further suggestions were collected on the use of accreditation standards and the method of evaluation during the survey.

Iran’s national hospital accreditation system launched in 2012 and applied to all public and private hospitals. Its goal was to promote continuous quality improvement in hospitals. The procedure was based on sets of standards, criteria and indicators to ensure that hospitals use recommendations for good clinical practice, and medical and professional guidelines. The transition from the traditional hospital evaluation system to a national comprehensive hospital accreditation system has to be managed carefully. Iran’s hospital accreditation system is in its infancy. In order to customise the accreditation system with the resources and capabilities of Iranian hospitals the development of the hospital standards has to be done gradually. The triad of structure, process and output/outcome was considered in the first version of hospital standards. However, more weight has been given to the structural and procedural standards (11). The belief is that the hospitals’ structures and processes should be improved in order to improve hospital outcomes. The standards will gradually be supplemented by indicators that are more clinical.

Joint Commission on Accreditation of Hospitals (JCAH) published its first hospital standards in 1952. The accreditation standards have grown considerably over the years in quantity, focus and quality. When first developed, these standards were primarily structure standards. More process-oriented standards were introduced to manual and later outcome-related standards were added. The current list includes more process standards than structure, therefore moving away from distinct “departments” to functions (13).

A team of surveyors were formed to carry out the hospital accreditation survey in Iran. Surveyors attended several initial and ongoing training programmes to improve their knowledge and skills in hospital evaluation and accreditation procedure. However, it takes time to enhance their competencies. The credibility and validity of the hospital accreditation programme largely depends on the team of surveyors (1). In order to ensure consistency in the way the accreditation procedure is applied across all hospitals and to ensure that its fundamental principles are complied with, an “accreditation surveyor’s charter” has been produced and intensive applied education and training courses were developed for surveyors.

The gradual development of the hospital accreditation system and its annual assessment provide an opportunity to address questions raised by hospital managers and employees, surveyors and healthcare accreditation experts. As a result, Iran national hospital accreditation system has gone under a systemic change in 2015. These changes were planned in 4 phases: situation analysis, planning, implementation and evaluation.

A literature analysis of experiences of hospital accreditation in other countries was conducted. As a result 62 hospital accreditation bodies in 49 countries were studied regarding to their accreditation model, governance, structure, content of the standards, methods of accreditation, number and type of surveyors, type and period of surveyors’ training programmes, etc. Furthermore, a literature review of hospital accreditation challenges and problems in Iran were conducted. 33 hospitals were visited in Aug and Sep 2015 and meetings were held with hospital managers and employees to discuss their expectations of the national hospital accreditation system. Several focused group discussion sessions were held with surveyors and healthcare experts in Iran. The challenges of Iran hospital accreditation system were identified and the solutions were discussed.