How can Iran’s hospital accreditation standards align with ISQua?

Abstract

Background

Hospital accreditation is a voluntary program that external evaluators evaluate hospitals based on predetermined standards. Well-designed standards play a crucial role in achieving the objectives of accreditation namely improving quality and ensuring patient safety. The aim of this study is to compare Iran's hospital accreditation standards with the requirements of the International Society for Quality in Health Care (ISQua) and propose corrective measures to enhance service quality.

Methods

This study employed a mixed-methods (quantitative-qualitative) sequential explanatory design, conducted between 2022 and 2023. Data were collected from 233 employees involved in the accreditation process at selected hospitals and analyzed using Excel software, based on a researcher-developed checklist aligned with ISQua requirements. Additionally, 19 accreditation experts were interviewed using a content analysis approach, and corrective solutions were proposed. The qualitative data were analyzed using MAXQDA software.

Results

Compliance with ISQua’s standards averaged 0.80, with the content and framework of standards scoring 0.82 and 0.76, respectively. High compliance was observed in patient referrals (0.99), while quality care reporting exhibited notably low compliance (0.33). The recommended solutions were categorized into three main areas: revising standards, improving the education process, and reforming governance policies. Furthermore, 20 subthemes were identified.

Conclusion

The results indicate satisfactory compliance with the accreditation standards of Iranian hospitals aligned with ISQua’s guidelines. Therefore, it is crucial to implement both corrective measures and supplementary initiatives to enhance these standards and better align them with ISQua Association’s requirements. To identify opportunities for improving Iran's accreditation standards, it is necessary to revise the structure and composition of these standards in accordance with the findings and to reflect the diverse range of hospitals across the country. By evaluating the standards based on evidence and real-world conditions, steps can be taken to advance the current status and achieve the objectives of accreditation. Additionally, the continuous and practical training of managers and stakeholders involved with the standards is key recommendation of this study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14562-7.

Background

Quality improvement is a strategic priority for all healthcare systems. Globally, accreditation has a progressive position in quality improvement strategies. Accreditation is described as an external evaluation of compliance of healthcare institutions with predefined standards [1], which is carried out by governmental or non-governmental entities and can be either voluntary or mandatory. The scope of accreditation can range from the entire healthcare facility to just a specialty or even a subspecialty [2, 3]. External review systems facilitate organizational changes, increase service quality, and strive toward quality standards [2]. Also, Hussein et al. reported that hospital accreditation could improve safety culture as well as performance criteria of the process, efficiency and length of patient stay [4] External evaluation programs are an important strategy employed by various countries to review and improve quality and safety standards and to achieve improvements in organizations or services [1]. Globally, External evaluation programs are known as an important driver for improving organizational and clinical processes and safety outcomes [5–7]. Hospital accreditation programs have progressed and become an integral part of health care systems [8, 9]. In Iran, the government is in charge of providing healthcare services [10] and since this responsibility rests with the MoHME, this ministry must use the most effective strategies and policies to achieve health goals. This issue requires identifying the health needs of society and using scientific and new planning and policy-making methods [11]. The Department of Evaluation and Accreditation of Medical Centers of the MoHME plays a key role in ensuring the provision of safe, effective, and quality healthcare services and intends to assure access to healthcare services by accredited medical centers. Therefore, during the last decade, effective measures have been taken by using accreditation standards. The standards and metrics of Iran’s hospital accreditation program were first published in 2012 by the Ministry of Health and Medical Education (MoHME) [12]. In Iran, all hospitals are required to obtain and renew an accreditation certificate on an annual basis, as the reimbursement rate of medical insurance funds is contingent upon the accreditation status of healthcare providers [13]. The accreditation model of the Iranian health system is comparable to that of the United States, which encompasses structural, result, and process standards [14]. The large number of standards, lack of transparency of standards, unbalanced attention on processes, structures, and outcomes in the compilation of hospital standards, using similar standards for all types of hospitals, and using similar weights for standards were among the challenges of the initial standards. Inadequacies of accreditation standards can lead to failure to achieve goals [15]. Therefore, Iran’s hospital accreditation standards have been removed, integrated, expanded, and generally improved during the past years. Such that the fifth round of standards, as the latest version, has 504 standards categorized in 3 axes and 19 sub-axes. Considering the changes and revisions made in Iran’s hospital accreditation standards, it seems necessary to investigated the effectiveness of the changes and compare them with the requirements of the leading organizations.

The ISQua was established in 1995 in Australia. Its remit includes the exchange of information on accreditation activities at the international level, the design and publication of guidelines and standards, and the guidance of activities related to accreditation program. ISQua, the largest accreditation agency in the world, operates in the field of accreditation training and consulting. The confirmation of accreditation indicates the performance of the accrediting agency [16]. The guidelines published by this association include requirements for compiling and editing accreditation standards. It is necessary to approve accreditation standards by ISQua, which paves the way for accepting the accreditation system of Iran by other countries. Therefore, this issue will play a significant role in flourishment of the health tourism industry of the country. Approving the standards by the ISQua would eliminate any ambiguity about them. AlKhenizan et al. Emphasized that accreditation conducted by institutions adhering to ISQua principles represents a critical process for ensuring compliance with established standards and international best practices [17]. As ISQua collects requirements for the successful implementation of accreditation programs and performs continuous field investigations, a comparison of the status of accreditation standards with the requirements of this association reveals the current shortcomings and facilitates the effective implementation of the program. Consequently, the objective of this study was to ascertain the extent to which Iran’s hospital accreditation standards align with the requirements set forth by ISQua. The findings of the current study can be used by policymakers to enhance accreditation standards.

Methods

This study employed an Explanatory Sequential Mixed Methods Design, conducted between 2022 and 2023. Initially, in order to compare Iran’s hospital accreditation standards with those of the International Quality Association, a quantitative approach was employed. The initial step was to create an evaluation checklist based on ISQua standards [18]. The validity of the checklist was evaluated by revising the initial items by the research team. Next, validity was quantitatively evaluated by obtaining the opinions of 14 accreditation experts. The Content Validity Ratio was employed in order to ascertain that the most crucial and accurate question was selected. Furthermore, the Content Validity Index was utilised in order to guarantee that the questions were devised in the optimal manner to evaluate the content. The final version of the checklist includes 49 items categorized into two pillars: the ‘framework of standards’ and the ‘content of standards.’ The former includes 13 items, whereas the latter contains 36 items. The content of the standards pillar includes organizational planning and performance, quality improvement, safety and risk management, and service recipients’ rights. The checklist items were evaluated based on a three-point Likert-type scale ranging from strong noncompliance (score of zero) and relative compliance (score of one) to strong compliance (score of two). Hospitals in the Lorestan province were selected as the sample to determine the compliance of Iran’s hospital accreditation standards with ISQua’s requirements.

As a member of the research team was living in Lorestan province and easy of access to hospitals and healthcare staff e of this province, as well as long-term cooperation with them, hospitals of the Lorestan province were chosen as the research sample; so that the data of the quantitative part were collected swiftly. There are various types of hospital at Lorestan, including teaching and non-teaching hospitals, hospitals affiliated to social security organization, and private hospitals, out of which four are categorized as teaching hospitals, 10 public hospitals, and three are private hospitals. Criteria such as participating in at least in two rounds of accreditation by the MoHME or being in charge of implementing some standards in hospitals were considered as inclusion criteria, based on which 306 employees were identified and recruited by the research team. Data collection checklist was designed using a Google form. Then, data were transferred to Excel and analyzed based on the research objectives.

To analyze the collected data, the following values ​​were considered to compare the general conclusions. In other words, to determine the degree of compliance of the checklist with ISQua requirements, the average value of each item of the checklist was calculated and then the average value of the entire checklist was compared with the following values.

A score between zero and 0.2 indicates a strongly poor compliance, 0.21 and 0.40 poor compliance, 0.41 and 0.60 moderate compliance, 0.61 and 0.80 good compliance, and 0.81 and 1 strongly good compliance. The identified challenges and shortcomings from the completed checklist were used to inform the design of semi-structured interview questions for accreditation experts (Additional file 1: Interview guide).

In the subsequent phase, a qualitative approach to content analysis was utilized with the objective of identifying a solution that would enhance compliance. In this method, the data collection tool was a semi-structured interview with 19 experts, selected using purposive sampling. The criterion for entry into the study is that the employees in question are related to and familiar with the standards and accreditation implementation process. The interviewees, apart from the participants of the quantitative phase, were recruited among accreditation experts across the country.

The interviews lasted 30 to 45 min and were audio-recorded. The primary focus of the interview was to ascertain the experts’ views on the deficiencies that had been identified.

In addition to audio recording, field notes were also taken to ensure greater accuracy of data collection. Interviews continued until researchers felt that new information could no longer be obtained with the inclusion of new samples after 19 interviews. We utilized the content analysis method developed by Elo and King, which facilitated the systematic categorization of data into primary themes and sub-themes. The inductive analysis was carried out with meticulous attention, involving persistent engagement with the data to achieve an in-depth comprehension. Eventually, data analysis was performed using inductive approaches using MAXQDA software. The Guba and Lincoln [19] criterion of reliability was used to evaluate the quality of the qualitative results. Additionally, the research objectives and methods underwent a thorough review by the university’s Internal Research Ethics Committee (IR.SBMU.SME.REC.1401.018). The study’s processes and aims were clearly communicated to the participants, who provided their written consent prior to joining the study. They were also guaranteed data confidentiality. The reporting of qualitative studies was guided by the integrated standards of the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results

In order to address the challenges identified in the quantitative part of the study, 233 participants completed the relevant checklist, resulting in a response rate of 76%.

The distribution of organization position of hospital employees who participated in the quantitative section is as described in Table 1.

Table 1.

Distribution of staff positions in selected hospitals participating in the research

Position	nurse	Support staff	Health experts	Safety experts	Quality improvement experts	financial manager	head nurse	Supervisor	Nursing manager	Hospital Manager	head of the hospital
Frequency	49	33	7	14	24	6	42	25	13	11	9
Percentage	21	14.2	3	6	10.3	2.6	18	10.7	5.6	4.7	3.9

The demographic information of the accreditation experts who participated in the qualitative section of the study are described in Table 2.

Table 2.

The demographic characteristics of the experts in the field of accreditation

Variable	Frequency	Variable	Frequency	Variable	Frequency	Variable	Frequency
Position		Work Experience		Education level		Gender
Managers and experts in accreditation (P3؛ P4؛ P5؛ P6)	4	Less than 10 years	1	PhD	13	Female	11
Members of the specialized accreditation panel (P7؛ P8)	4	11 to 20 years	7	Masters	5	Male	8
Accreditation experts (P9؛ P10؛ P11)	9	21 to 30 years	10	bachelor’s degree	1
Health management professors (P1؛ P2)	2	More than 31 years	1

The results show that the mean compliance rate of Iran’s hospital accreditation standards with ISQua was 0.80. The Accreditation Content of Standards Index’ and the Standards Framework’ showed an average compliance rate of 0.82 and 0.76, respectively (Table 3).

Table 3.

Evaluation of Iran’s accreditation standards based on ISQua’s requirements

Compliance	Average ± SD	Complete compliance (%)	Relative compliance (%)	Noncompliance (%)
Topic
Content of standards	0.82(± 0.34)	0.75	0.13	0.12
Framework of standard	0.76(± 0.39)	0.70	0.12	0.18
Total	0.80(± 0.36)	0.74	0.13	0.13

The average as well as the values ​​of full compliance, relative compliance, and non-compliance of each of the sub-axis related to the core standards are described in Table 4.

Table 4.

Evaluation of Iran’s accreditation standards content based on ISQua’s requirements

Compliance		Average ± SD	Complete compliance (%)	Relative compliance (%)	Noncompliance (%)
Topic
Content of standards	Planning and performance of organizations	0.82 (± 0.35)	0.75	0.13	0.12
	Quality improvement	0.74(± 0.39)	0.64	0.19	0.17
	Safety and risk management	0.85(± 0.32)	0.79	0.12	0.09
	Rights of Service recipient	0.86(± 0.30)	0.82	0.10	0.08

The views of hospital staff regarding the compliance of Iranian accreditation standards with ISQUA requirements are presented below (Table 5).

Table 5.

The views of hospital employees regarding Iran’s accreditation standards based on ISQua’s requirements

Number	standards	Average	SD
Content of standards
Planning and performance of organizations
1	Accreditation standards require hospitals to define their mission, vision, values, ethical principles, and strategic goals within a structured plan.	92.0	25.0
2	Accreditation standards mandate hospitals to have an operational plan.	89.0	0.28
3	Accreditation standards compel hospitals to focus on evidence-based and information-driven management practices.	0.89	0.25
4	The accreditation standards are aligned with higher-level laws and policy-making, including compliance with health and safety regulations, waste management, food and sanitation, information management, and pharmacology.	0.89	0.28
5	The accreditation standards require hospitals to develop and implement documented processes for human resource management.	0.77	0.36
6	Accreditation standards require hospitals to pay attention to the knowledge enhancement, skill training, and experience accumulation of their staff.	0.66	0.42
7	Accreditation standards necessitate hospitals to define the job descriptions of their employees.	0.68	0.42
8	Accreditation standards hold hospitals accountable for evaluating the performance of human resources based on their job descriptions.	0.72	0.40
9	The accreditation standards obligate hospitals to implement initial and ongoing training courses.	0.92	0.26
quality improvement
10	Accreditation standards require hospitals to have a continuous quality improvement program.	0.77	0.39
11	“Accreditation standards compel hospitals to develop processes related to quality enhancement and to measure their outcomes.”	0.73	0.41
12	Accreditation standards obligate hospitals to monitor and evaluate the quality of care based on appropriate indicators	0.78	0.34
13	Accreditation standards emphasize having a process-oriented approach to enhance processes.	0.79	0.35
14	Accreditation standards require hospitals to publicly disclose information related to the quality of care.	0.33	0.38
15	Accreditation standards mandate hospitals to oversee the adherence to clinical guidelines by the staff	0.88	0.27
16	Accreditation standards require hospitals to design and accurately complete health records for service recipients	0.64	0.37
17	The accreditation standards emphasise the importance of adhering to appropriate care patterns, which are defined by instructions, policies, and procedures.	0.95	0.18
Safety and risk management
18	The accreditation standards encompass criteria for risk management.	0.92	0.21
19	Accreditation standards require hospitals to have a risk management plan with a preventive approach.	0.94	0.22
20	Accreditation standards emphasize the existence of dimensions of a comprehensive risk management program (such as stating program goals, potential risks, possible consequences of risks, prioritization, enhancement interventions, and methods of monitoring and evaluation).	0.85	0.32
21	The risk management program is supported by guidelines, policies, or operational procedures.	0.75	0.41
22	In order to protect service recipients from the occurrence of unintended care events, accreditation standards require hospitals to implement processes designed to assess, report, analyse, and improve potential unintended even	0.89	0.29
23	Accreditation standards obligate hospitals to protect the health and safety of their staff.	0.97	0.16
24	Accreditation standards require hospitals to train staff on safe practices.	0.74	0.36
25	Accreditation standards mandate hospitals to comply with safety requirements for physical spaces.	0.94	0.18
26	Accreditation standards obligate hospitals to adhere to safety requirements for medical equipment.	0.90	0.25
27	Accreditation standards compel hospitals to observe safety requirements for non-medical equipment.	0.94	0.21
28	Accreditation standards bind hospitals to respect safety requirements for service recipients from aspects such as physical, chemical, biological, and psychological.	0.56	0.41
29	Accreditation standards necessitate hospitals to have a comprehensive infection control program.	0.77	0.37
Rights of Service recipient
30	Accreditation standards emphasize the continuity of service provision.	0.96	0.16
31	Accreditation standards underscore the necessity of systematically resolving patient grievances within an established and timely process.	0.87	0.26
32	Accreditation standards highlight the involvement of patients and their families in care.	0.89	0.30
33	Accreditation standards focus on recognizing and respecting the cultural background, perspectives, and preferences of patients.	0.74	0.35
34	Accreditation standards obligate hospitals to pay attention to the issue of access to care and to inform target groups about the services provided.	0.64	0.45
35	Accreditation standards emphasize the accurate assessment of service recipients	0.96	0.17
36	Accreditation standards emphasis the importance of appropriate and planned patient referrals.	0.99	0.07
Framework of standard
37	The primary goal of developing standards is to achieve a satisfactory level of performance and improve the quality of care.	0.86	0.30
38	The applicability of the developed accreditation standards (in terms of hospital type, unit, and healthcare services) is clearly delineated.	0.94	0.19
39	Revised or newly developed standards are made available to evaluators and those being evaluated according to a specific timetable and implementation plan.	0.92	0.21
40	A sufficient period of time is allotted for the review of implementation and compliance with the communicated requirements.	0.92	0.12
41	The standards are classified in an appropriate and logical manner, with titles and numbers assigned.	0.97	0.14
42	In the evaluation, the scoring framework for the standards is defined in a clear and appropriate manner, allowing for a transparent and consistent assessment.	0.88	0.29
43	The standards are accompanied by a comprehensive and transparent user guide, which includes all necessary documentation, evaluation methods, and data collection procedures	0.45	0.45
44	The necessary training for users of the standards (evaluators and those being evaluated) is provided in a clear and straightforward manner, ensuring that interpretation and use are unambiguous.	0.24	0.41
45	The standards are written in a clear and unambiguous manner, with the use of vague terminology avoided.	0.63	0.42
46	The use of acronyms is to be avoided, and if their minimal and unavoidable use occurs, an acronym guide is to be considered.	0.88	0.27
47	A transparent framework for evaluating hospital performance and conferring accreditation approval is established.	0.90	0.25
48	The assessment and ranking system are found to be satisfactory from the perspective of both organizations and evaluators.	0.52	0.43
49	Adequate time is allotted for the accreditation evaluation of the hospital.	0.75	0.40

For ‘content of standards,’ the sub-component of ‘appropriate and scheduled referral of patients’ had the highest average (0.99), while public reports of data on quality of care showed the least average (0.33).The degree of conformity of the main content of standards is presented in Table 4. Concerning the ‘framework of standards,’ the highest average (0.97) belonged to ‘appropriate and logical categorization of standards,’ and the lowest average (0.24) belonged to ‘training users of standards.’

The proposed adaptative solutions are categorized into three categories and 20 concepts (Table 6).

Table 6.

The proposed adaptative solutions

Category	Sub-Category
Modifying the approach of developing and revising standards	-Using an appropriate conceptual model to revise standards; -Reducing structural standards that are overlapped with other instructions; -Increasing outcome-related standards; -Maintaining examples of quality when revising standards; -Not emphasizing changing the number of standards; -Making standards more practical; and -Considering the diversity of hospital activities.
Improving the training process	-Expanding training programs on standards; -Embedding accreditation standards in medical curriculums; -Increasing interactions between those in charge of teaching standards in the Ministry of Health; -Developing standards and administration guidelines; -Holding virtual and shared training courses for users; -Devoting the responsibility of holding some training courses to the private sector or the quasi-government sector; and -Establishing the necessary arrangements to share experiences on implementing standards.
Revising governance-related policies	-Avoiding conflict of interests and lobbying in developing and revising standards; -Revising hospitals ranking system; -Forming a scientific committee for developing and revising standards; -Increasing engagement of accreditation experts and experts in related fields in revising standards; -Transparent policies on the implementation of mandatory standards; and -Increasing coordination and communication within the Ministry of Health in reviewing standards.

Revising the approach to developing and revising standards

This category applies policies and guidelines to revise standards in order to achieve comprehensive and highly valid standards. In this regard, it is necessary to use an appropriate conceptual model to categorize all standards, mainly by focusing on maintaining the association between various pillars, while considering real performance and hospital hierarchy. Based on reviewing previous revisions, some policies aimed to reduce the number of standards, and the emphasis has been on increasing the share of quality and outcome-related standards, while reducing standards that are mentioned in other instructions or are related to physical spaces.

One of the current problems is the emphasis on reducing the number of standards, while we should avoid quantitative attitudes and we should not sacrifice the content when revising standards; i.e., maintaining examples of quality are crucial (P7).

For future revisions to accreditation standards, it is necessary to consider a functional approach. In developing these standards, it is necessary to consider the hospital type that is, private, public, social security, armed forces, etc. A manager of the Accreditation Department of the MoHME emphasized that ‘Currently, the fifth edition of accreditation standards is administered, and the standards are largely based on a functional approach (P6)’.

Another declared that ‘documentation in accreditation’, an accreditation expert noted ‘documentation was emphasized at early editions of accreditation. Therefore, currently, documentation has a weak role in accreditation (P4)’.

Moreover, according to a member of the specialized panel for revising standards (affiliated to the MoHME), ‘during revising accreditation standards clarity of standards has become clearer using feedbacks and comments; so that, the use of ambiguous words has been minimized (P3)’.

Meanwhile, one expert believes that a logical and appropriate process has not been used to reduce the number of standards from the first to the fourth edition. ‘Most standards have not actually been removed, but are merged, if each measure is supposed to assess only one issue, not several (P8)’.

The an interviewee noted that ‘standards are not separated by specialty, number of beds, region, affiliation, and type of hospital; it is not possible to implement some standards in all hospitals (P10)’.

Improving the training process

This category concerns proposed solutions related to the training target groups, including methods, content, trainers, and sharing of experiences between hospitals. Such training is intended to fade ambiguity by empowering beneficiaries, managers, and employees to use standards.

‘Managers of medical universities do not receive sufficient training and there is no need for assessment or continuous education at the hospital level (P11)’.

‘It is of paramount importance that accreditation standards be integrated into the curricula of all medical and paramedical groups, and that primary training be provided to these individuals before they work in hospitals. This will not only enhance the legitimacy of the standards but also underscore the urgency of their implementation (P7)’.

‘Training for those who utilize standards must be reinstituted and made available on an ongoing basis. Currently, the training of managers and staff of quality improvement units is not a priority for the Ministry. However, the establishment of a virtual training platform following the COVID-19 pandemic has made it possible to initiate training at a lower cost and with greater effectiveness (P2)’.

‘The sharing of successful experiences and methods of implementing and executing standards in various hospitals is a highly beneficial practice. Currently, there are a number of disparate virtual channels for this purpose. However, it is necessary to undertake this task in a systematic manner, leveraging the expertise of experts and professors in the field of accreditation (P10)’.

Some interviewees noted ‘cascade training is not an appropriate method, as it depends on different conditions such as the level of interest, ability to transfer information, the level of learning, decisions related to the transfer all or part of the training due to conflict of interests and so on. Also, it is necessary to hold the training widely and to use a virtual platform (P11)’.

Revising governance-related policies

This category concerns general solutions that emerged from the opinions of accreditation experts. Therefore, it is necessary to seize the opportunity to use the capacities of experts through a scientific committee.

‘In some cases, the latest version of standards was available for experts interested in studying and learning. Hence, this pillar was rich. Nevertheless, some pillars did not contain sufficient standards due to lack of experts; I mean well-balanced and appropriate standards are not written (P8)’.

Some interviewees believed in revising the measurement to achieve hospital accreditation standards and hospital rankings.

‘The standards outline the need for certain structural elements and physical resources which may not be feasible for implementation across all national hospitals. These requirements fall under the category of compulsory standards; they are deemed essential yet, due to varying circumstances and insufficient hospital revenues, providing them remains a challenge. This discrepancy not only undermines the integrity and significance of these standards but also impacts their mandatory status (P4)’.

‘In order to enhance the effectiveness of the accreditation process, it is imperative to expand the roster of the specialized accreditation committee by incorporating more seasoned administrators and distinguished academics from the field. Given that a primary objective of the accreditation initiative is the preservation and enhancement of healthcare service quality, the development of standards should align with this aim. Continuous refinement of these standards is crucial, necessitating a robust, diverse, and experienced team to uphold and advance them (P8)’.

Discussion

The results indicate that the degree of conformity between the accreditation standards of Iranian hospitals and ISQua requirements was 0.80 on average. In accordance with the guidelines on the national accreditation standards [20] of Iranian hospitals, The standards are organized into three general areas :‘leadership and management’ (seven pillars), ‘care and treatment’ (ten pillars), and ‘supporting service recipients’ (two pillars).

Based on the opinions of hospital employees, the clarity of standards had an average of 0.63.

In the current version of the standards [20], each standard contains a series of relevant metrics that are categorized in a table, and each metric includes evaluation criteria and explanations to clarify the metrics further. However, considering the low score obtained (i.e., an average of 0.45) for the item related to the availability of a comprehensive and separate guide for administering standards, it seems that more than complementary explanations provided in the original version were needed. On the other hand, some interviewees emphasized developing a comprehensive guide for standards to maximize the administration of standards and even guide their evaluation.

AlKhenizan et al. compared Saudi Arabia’s accreditation standards with ISQua requirements and reported that their standards are repetitive, complex, and vague, and also are poorly organized so that even do not have heading and subheading. In addition, the standards lack additional explanations to describe the purpose of each standard and how to implement it, and measurable elements are not been determined [17]. Mosadeghrad et al. [15] showed that some factors that cause dissatisfaction among hospital managers were related to the ambiguity of standards, emphasis on documentation, and sectoral approach to standards. It is noteworthy that, as they investigated the second edition of the standards, their study contradicted the findings of this study. It seems that revisions and improvements in standards are among the reasons for this contradiction. Because in this study, the standards mentioned in the fifth version are evaluated.

AlKhenizan et al.‘s showed that process of developing, evaluating or revising the CBAHI standards has not been well organized [17]. Some studies also mentioned the irrelevance of some standards [21] and the uncertainty of the results [22] with the comparisons.

On the other hand, Mosadeghrad et al. mentioned the high number of standards in the second edition as a major factor in managers’ dissatisfaction. However, the number of standards was reduced from 8,104 in the first edition to 504 in the fifth edition, mainly in the fourth version.

According to the opinions of hospital employees, items related to the classification, numbering, and titling of the standards showed full compliance (i.e., an average of 0.97). Based on the current edition, the standards include 19 pillars as the main components, 110 quality standards, and 505 separate measures, including 212 first-level measures, 208 s-level measures, and 85 third-level measures. According to ISQua’s requirements [18], it is necessary to define a transparent framework for ranking the performance of hospitals and issuing accreditation approval. However, from the perspective of the selected employees, this was not observed in Iran’s accreditation program, and an average of 0.52 was attributed to this option.

Ghadami et al. [23]evaluated the third edition of standards and concluded that ranking most hospitals at the first level (i.e., scores of 61–80) is among the weaknesses of evaluations, as the score range is wide. These findings are consistent with those of the current study.

Currently, the hospital ranking system includes six categories (excellent, superior, one, two, three, and four), and the requirements of each category are defined in terms of the percentage of realization. As the issued certificate for each hospital includes the overall score, the difference between hospitals concerning the strengths and weaknesses in each pillar needs to be reported. One expert believed that providing comprehensive reports on the progress of standard implementation in hospitals was an appropriate solution. Ghadami et al. [23] showed that the division of standards into three areas, mandatory, basic, and ideal, did not affect the accreditation process, and hospitals that do not have the conditions to fully implement mandatory standards should not enter the accreditation process.

The majority of the interviewees mentioned the existence of clear policies regarding meeting mandatory standards and their implementation.

Pavlova et al. showed that clarifying the operational process of accreditation is an important factor that can help policymakers and stakeholders in the successful implementation of the accreditation program. The effectiveness of the integration of accreditation standards depends on the proper understanding of accreditation and the mechanisms through which the standards are applied. The stages of standards integration are sequential, interconnected, and influenced by culture, teamwork, and leadership involvement [24].

According to ISQua’s requirements [18], it is necessary to specify the administrative scope of accreditation standards based on the hospital type in a transparent manner. Currently, in addition to the general criteria, only the special standards for psychiatric hospitals have been developed separately, and the evaluation of these hospitals not only includes the package of national accreditation standards, but also includes the package of specialized psychiatric criteria. Moreover, separate standards have been developed for a limited number of surgical centers.

Similar findings were reported by Raiesi et al. [25], who mentioned that some standards noted in the third edition could not be implemented and evaluated. Mosadeghrad et al. [26] showed that some accreditation criteria cannot be implemented in hospitals in some countries. The structure, ownership, and variety of hospitals should be considered when developing standards, which will translate into the increased enforceability of standards. These findings are consistent with those of the current study. The World Health Organization mentioned the uncertainty of having standards for all hospitals as a main challenge of the accreditation program in its Eastern Mediterranean Region [15]. US state and local accreditation agencies also report the issue of considering differences among hospitals when implementing accreditation programs [27].

Due to differences in impact, importance, and associations between standards and MoHME’s goals, the weighting system of criteria was revised when developing the fifth edition of accreditation, while administering higher weights for standards related to patient safety, compliance with Islamic laws, and crisis management.

Raiesi et al. [25] mentioned ambiguity in scoring and weighting mechanisms as a main challenge of the third edition of the hospital accreditations program. Also, Mosadeghrad et al. [26] noted similar weighting of all criteria as the main reason for managers’ dissatisfaction when administering the second edition of the accreditation program. The aforementioned studies investigated the second and third editions of accreditation programs; therefore, their findings are inconsistent with the present study.

In Pavlova et al. [24] emphasized outcome-related standards and reducing the standards based on organizational structure and process.

Concerning the public release of information on quality of care, no criterion was observed in the comprehensive guide to Iran’s hospital accreditation standards. It is necessary to publish information and criteria related to the performance and quality of care provided in hospitals (e.g., patients’ and their companion satisfaction level, patient safety criteria, staff safety, and infection control) to allow service recipients to select a provider by considering quality indicators. The issue of service recipient rights showed average of 0.86. and was in accordance with ISQua’s requirements [18] on continuity of service delivery, handling of patients’ complaints, participation of patients and families in care, respect for the cultural background and patients’ preferences, access to care, informing target groups, correct assessment of the service recipients as well as the proper and planned referral of patients.

Based on ISQua’s requirements [18], it is necessary to provide the necessary training for the users of the standards in a way that makes their interpretation and administration easy and clear. Hospital staff evaluated this case as low compliance (i.e., an average of 0.24). Cascade training method is effective training method.

Azami et al. also noted that 85% of participants mentioned the need for accreditation training, which aligns with the current study [28].

Sharing evidence, as well as identifying and addressing gaps and areas for quality improvement, are emphasized by some studies [29, 30]. Successful operation of an environment or an organization has the potential for benchmark by other environments. In this regard, there are mechanisms that pave the way for benchmark or even prevent it. It is necessary for low and middle income countries that aim for successfully implementation and maintenance of their national accreditation programs to consider and follow up such mechanisms and models [31].

Improving the standards of health care services is one of the commitments of the providers in any country. Since the national hospital accreditation program in Iran was announced by the Ministry of Health and Medical Education in 2012, it can be said that the standards are undergoing an evolutionary process. Paying attention to the principles of developing accreditation standards by the ISQua and using the world’s experiences in developing and reviewing standards will lead to achieving the goals of the accreditation program and conducting a proper evaluation of hospitals. This study has provided useful information on the alignment of the content of national accreditation standards with the requirements of the ISQua, which can be used by relevant policy makers in the development and review of standards. In practice, the authorities of the hospital accreditation system in the country should pay special attention to the role of appropriate accreditation standards and continuously update and improve them. Improving and continuously updating the content of accreditation standards is a tool for organizational change and development and for ensuring the correct delivery of services, which can be used in future planning and lead to quality improvement, safety, increased responsiveness and public confidence in the quality of services, the provision of appropriate and effective services to patients, increased patient and staff satisfaction, and ultimately improved hospital performance. The proposed solutions of this study are simple, feasible and compatible with the current situation in Iran.

The study only included hospitals from one province in the quantitative section, while the qualitative section provided adaptive solutions based on national accreditation experts’ opinions. Another limitation of the current study is that few articles compared the accreditation standards against ISQua requirements. Hence, there is a need for performing more studies on the evaluation local accreditation standards of various countries; so that developing countries can evaluate their local accreditation programs with the aim of achieving improvements.

While previous research has explored various aspects of healthcare quality and safety in Iran, there has been no comprehensive assessment of the extent to which Iran’s standards comply with international criteria. By identifying specific areas of divergence and proposing targeted solutions, this study not only contributes to ongoing efforts to enhance healthcare quality and patient safety in Iran but also provides a unique perspective that can inspire similar initiatives in other developing countries. Furthermore, this research addresses a significant gap in the global literature regarding the compliance of hospital accreditation standards with ISQua criteria, offering valuable insights that can serve as a reference for future studies and practical applications in the field of healthcare accreditation. However, the limitations of this study should be considered when interpreting and using its data.

Conclusions

The accreditation system in Iran faces various challenges, such as issues with the national accreditation standards, financial constraints, and inadequate infrastructure. To address these challenges, several adaptive solutions are proposed, including expanding training programs, modifying the accreditation process, developing a guide for using standards, cascading successful experiences, reducing structural overlap, increasing outcome-focused standards, emphasizing practicality, addressing hospital diversity, using appropriate conceptual models, avoiding conflicts of interest, modifying the hospital ranking system, and forming a scientific committee for revising standards. It is necessary to rank hospitals based on available evidence and in accordance with existing standards, and political and economic pressures should not affect this matter. Availability of a comprehensive report on the strengths and weaknesses of the accreditation program can pave the way for hospitals to take more practical and extensive measures to implement the standards more successfully. By providing infrastructure for the implementation of standards, considering the structure, diversity, and ownership of hospitals, particularly those in the catchment area of deprived universities (i.e., in terms of financial resources), further steps can be taken to institutionalize standards. Applying existing virtual platforms to train managers and users of standards in hospitals is also one of the suggestions of the current study to achieve accreditation goals.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ISQua

International Society for Quality in Healthcare

Author contributions

TP is a graduate student in the field of Health care management, who has been actively engaged in each step in the research process(Concepts, Design, Literature search, Data acquisition, Data analysis, Statistical analysis, Manuscript preparation, Manuscript editing, and Manuscript review). LSH was the study guide and participated in the entire study process. FGH participated in data analysis and writing the Manuscript.

Funding

The study was funded by Shahid Beheshti University of Medical Sciences (43002673).

Data availability

The data that support this study will be shared upon reasonable request to the corresponding author.

Declarations

Ethics approval and consent to participate

The research purpose and methodology were reviewed and approved by the Internal Research Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.SME.REC.1401.018). Informed consent was obtained from all the participants. The informants gave written informed consent to participate after receiving written and verbal information about the study. Participation was voluntary, and the participants could withdraw at any time before publication without consequences. The study was conducted in accordance to relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.