Responses to the Criticisms about "The Accreditation of Hospitals in Iran".

Dear Editor-in-Chief

The authors should thank the authors of letter entitled “Iran Hospital Accreditation system” for their criticisms. In response to this letter, which includes some criticisms about our letter entitled “The Accreditation of Hospitals in Iran”, the following points can be made:

The overall purpose of this letter was to look at the status of accreditation from the past to the present time and had only given a general overview and the details had been avoided. This overview had been provided based on the valid references some of published by the authors of this letter. However, unfortunately, the order of these references had been displaced in the reference section. The correct order was as follows:

Lee HR (2012). The role of the Korean Hospital Association in Korea’s healthcare accreditation system. J Korean Med Assoc, 55(1): 23–30.

Mate KS, Rooney AL, Supachutikul A, Gyani G (2014). Accreditation as a path to achieving universal quality health coverage. Global Health, 10(1): 68.

Donahue KT, Vanostenberg P (2000). Joint Commission International accreditation: relationship to four models of evaluation. Int J Qual Health Care, 12(3): 243–246.

Dastur F (2012). Hospital Accreditation: A Certificate of Proficiency for Healthcare Institutions. J Assoc Physicians India, 60: 12–13.

Warren C, Abuya T, Obare F, Sunday J, Njue R, Askew I, et al. (2011). Evaluation of the impact of the voucher and accreditation approach on improving reproductive health behaviors and status in Kenya. BMC public health, 11(1): 257.

Bahadori M, Ravangard R, Yaghoubi M, Alimohammadzadeh K (2014). Assessing the service quality of Iran military hospitals: Joint Commission International standards and Analytic Hierarchy Process (AHP) technique. J Educ Health Promot, 3: 98.

Kweon TD (2011). Update of sedation in view of Joint Commission International standards. J Korean Med Assoc, 54(12): 1284–1288.

Bahadori M, Shams L, Sadeghifar J, Hamouzadeh P, Nejati M (2012). Classification of health structural indicators using scalogram model in Golestan Province, Northern Iran. Iran J Public Health, 41(5): 58–65.

Smits H, Supachutikul A, Mate KS (2014). Hospital accreditation: lessons from low-and middle-income countries. Global Health, 10(1): 65

Hospital Accreditation program was formally established in the United States in 1951 by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Then, it was spread to Canada and Australia during the 1960 and 1970 and then, to the European countries in 1980, and finally, it was extended throughout the world in 1990 (1–3). Accreditation is usually a voluntary program performed by the non-governmental organizations in which the health service organizations are accredited by external trained surveyors based on the compliance with pre-established standards (3–5).

In Iran, the hospital accreditation standards have been developed by literature review, as well as the adoption of accreditation programs of Joint Commission International (JCI), Lebanon, Egypt and France. Generally, the origin of these programs, like other hospital accreditation programs around the world, is the accreditation program of Joint Commission on Accreditation of Healthcare Organizations (6). This is contrary to the criticism made and put forwarded by the author/s of “Iran Hospital Accreditation System”. Because in the reference they have been used, there is not any word about and reference to the US, Canada and Australia.

The evolution of hospital accreditation standards in different countries show that these standards have changed from only the structural standards to the standards based on continuous quality improvement. In general, the assessment standards of structure, process and outcome have gradually replaced the traditional accreditation standards, which have solely been based on the data and physical structures (6). The evolution of accreditation programs in different countries is determined based on the characteristics and level of development of their health services. Most experiences in the field of accreditation are related to the high-income countries, like the United States, which have strong central control mechanisms, as well as the appropriate health systems. In these countries, accreditation is moving from simple and structural indicators to the standards based on the outcomes of health care (1, 7). Iran also is not an exception and its history and evolution of hospital accreditation programs shows that there has been a hospital accreditation program from many years ago, however, its structured format entitled “Criteria and standards of hospital accreditation” has been set by the Ministry of Health’s vice-chancellor for Treatment and notified and delivered to the Universities of Medical Sciences by the related Minister from July 1997. These criteria and standards were mainly focused on the structural standards, including human resources, physical space, equipment and some instructions, so that Bahadori et al. in their study have concluded that accreditation only based on structural indicators and standards is not enough and has flaws and shortcomings (8). Although after this period, the assessment and evaluation of the qualitative indicators, particularly the qualitative indicators of Hospital Emergency Departments, was also mandatory in 2004 and 2006, the idea of revising the hospital accreditation system of Iran was developed because of the scope of accreditation in the world and the criticisms about the hospital accreditation program in Iran. Finally, a new program entitled “hospital accreditation standards for hospitals in Iran” was delivered to all Universities of Medical Sciences in 2010 (6, 8–9). Therefore, what has been mentioned in “The Accreditation of Hospitals in Iran” about the evolution of accreditation is evidence-based and based on the valid references?

Overall, several studies have been conducted on the hospital accreditation programs around the world and from many years ago. However, there are only few studies on many aspects of implementing accreditation and its effects, and the results are not stable. Nowadays, there are many requests for conducting studies in the field of accreditation. The researchers acknowledge that the evidence to support the effects of accreditation on improving the quality of services is low and insufficient (2, 10). Some of key findings of studies conducted in the field of accreditation indicate that the healthcare workers ‘view about the accreditation is not perfect and complete and, therefore, the researchers are trying to develop these views. Some researchers believe that accreditation is a tool to help external stakeholders in order to find out how quality and safety are managed in an organization. According to them, accreditation is an effective strategy for improving the team decisions and organizational performance and for assuring quality. Some critics also believe that accreditation leads to bureaucracy and spending much time, however, it has limited impacts on improving patient care. The findings of some studies in the field of hospital accreditation have showed that preparing for accreditation is increasing, although its organizational effects and effectiveness are not clear yet (2). As mentioned above, in some studies, the researchers have concluded that implementing accreditation have had the limited impacts on improving patient care, not clear organizational effectiveness, and mentioned the following problems: It is a bureaucratic process; It is very time-consuming; It cannot have a significant impact on patient care; It is very costly; There is no unity among assessors and surveyors and there is some problems with standards (2, 11). Although there is not any study on various aspects of accreditation and its effects on the quality and safety of services and other organizational impacts of implementing hospital accreditation in Iran, because the Iran national hospital accreditation standards are based on the standards of JCI and the programs of some of the leading countries in this field, it cannot be excluded from it.

The authors of “Iran Hospital Accreditation system” have stated that” A team of surveyors were formed to carry out the hospital accreditation survey in Iran” and for this sentence have provided Reference No.. 1, while it seems that this reference has nothing to do with Iran and has been published in 1998. It is better to provide any other valid and relevant reference. In addition, there is not any valid evidence and references for some criticisms, for example, “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 more clinical indicators.” or “accreditation surveyor’s charter” as well as the changes in the Iran hospital accreditation system and the last paragraphs.