Developing national meta-accreditation standards for medical education accreditation bodies in Iran: a mixed-methods standards development and consensus study

Abstract

Ensuring the quality and credibility of medical education systems increasingly depends on robust accreditation mechanisms, yet the performance of accreditation bodies themselves often remains insufficiently evaluated. Addressing this gap, this study developed and validated the first national meta-accreditation standards for Iran’s Ministry of Health and Medical Education. Using a rigorous mixed-methods design, the study integrated insights from semi-structured interviews with 13 national experts, a comparative review of six international recognition systems, expert panel consensus, and a national survey of 90 stakeholders. From an initial pool of 184 standards, systematic refinement led to a final set of 51 standards. Stakeholder evaluation demonstrated strong consensus across practicality, necessity, and transparency (76–94%), with all standards exceeding the predefined 70% agreement threshold. The resulting framework is structured across three domains: structure and formality, accreditation processes, and accountability and quality improvement. By aligning national needs with international benchmarks, these standards enhance transparency, consistency, and trust in accreditation systems. The high level of expert agreement and methodological rigor underscore the framework’s readiness for implementation and its potential as a model for strengthening meta-accreditation in similar centralized health education systems.

Introduction

Accreditation is widely recognized as a cornerstone mechanism for ensuring and enhancing the quality of higher education and professional training systems. By providing a structured framework for evaluating institutions and programs against predefined standards, accreditation promotes accountability, transparency, and continuous quality improvement^1–3. In medical education, its role is particularly critical, as the quality of educational processes directly influences the competence of healthcare professionals and, ultimately, the safety and effectiveness of healthcare systems^2,4. Beyond its regulatory function, accreditation supports curriculum development, shapes educational practices, and fosters a culture of institutional self-assessment and ongoing improvement^3–5.

Over recent decades, the rapid expansion of accreditation systems worldwide has led to the establishment of numerous accrediting bodies operating under diverse structures, standards, and evaluation approaches. While this expansion has strengthened quality assurance efforts, it has also introduced important challenges, including variability in evaluation processes, inconsistency in accreditation outcomes, and limited comparability across systems^6,7. Such challenges may weaken the credibility of accreditation decisions and hinder mutual recognition of qualifications across national and regional contexts.

In response to these concerns, the concept of meta-accreditation—defined as the external evaluation and recognition of accrediting bodies—has emerged as a critical mechanism for strengthening quality assurance systems⁷. By shifting the focus from evaluating educational institutions to evaluating the accrediting organizations themselves, meta-accreditation ensures that these bodies operate according to transparent, valid, and internationally aligned standards. This higher-level oversight enhances the reliability, coherence, and legitimacy of accreditation processes.

Several international frameworks have been developed for this purpose, including those associated with organizations such as ASG-QA, APQR, WFME, INQAAHE, CHEA, and EQAR, which aim to enhance the transparency, comparability, trust and credibility of accreditation systems and facilitate cross- border recognition and collaboration^8–13. These frameworks aim to promote transparency, comparability, and trust in accreditation systems, while facilitating cross-border recognition and collaboration. Although some frameworks are designed for general higher education, others—such as WFME—are specifically tailored to the unique requirements of medical education.

In Iran, accreditation in medical education has expanded substantially in recent years under the supervision of the Ministry of Health and Medical Education (MOHME), with multiple bodies responsible for evaluating educational programs and institutions^14–16. While this expansion reflects a strong national commitment to quality assurance, it has also created challenges related to coordination, consistency in standards implementation, and alignment of evaluation practices across accrediting bodies^6,17,18. Notably, the general medical education accreditation system has achieved international recognition (e.g., through WFME), whereas other accrediting bodies continue to operate without formal external validation^13,14.

Strengthening meta-accreditation in this context extends beyond educational quality and has broader implications for health system governance. In health systems, the credibility of accreditation decisions is not only an educational concern; it influences the mechanisms through which healthcare professionals are trained, assessed, and prepared to meet population health needs. By enhancing the reliability and coherence of accreditation systems, it contributes to improved institutional trust, more effective policy alignment, and better system performance. Given the close interdependence between medical education and healthcare delivery, ensuring consistent and credible accreditation processes is important for supporting patient care quality and overall system effectiveness⁴.

Despite these developments, the absence of a formal and nationally integrated mechanism for evaluating accrediting bodies represents a critical gap in the Iranian medical education accreditation system. Without a structured meta-accreditation mechanism, challenges related to consistency, transparency, accountability, and the credibility of accreditation decisions may persist^19,20. Previous studies in Iran have primarily focused on the accreditation of educational programs and institutions, whereas the systematic evaluation, recognition, and quality assurance of accrediting bodies themselves have received limited attention^19,20, To address this gap, this study aimed to develop national meta-accreditation standards for educational accreditation bodies in Iran through a sequential standards development and consensus-building process informed by qualitative and quantitative methods. Drawing on international recognition models, expert perspectives, and national stakeholder evaluation, this study sought to establish a context-adapted set of standards to strengthen the quality, consistency, transparency, and credibility of accreditation systems²¹.

Results

A total of 13 national experts participated in the qualitative interviews. The demographic characteristics of participants are presented in Table 1. The majority were female (n = 8, 61.5%), held PhD degrees (n = 13, 100%), and had over 20 years of experience (n = 11, 84.6%). Most participants were members of accreditation secretariats (n = 11, 84.6%) and served as educational group managers (n = 9, 69.2%).

Table 1.

Demographic characteristics of participants in qualitative interviews

Sex	Educational Group Manager	Educational Executive	External Evaluator	Role in Designing Accreditation Systems	Member of Accreditation Secretariats	Experience		Academic Degree			Education
						>20	<20	Professor	Associate Professor	Assistant Professo	MD/ PhD	PhD	MD
Female	1	1	2	2	1	-	2	1	1	-	1	-	1
Male	5	9	11	7	7	-	11	10	1	-	-	3	8
total	6	10	13	9	8	-	13	11	2	-	1	3	9

Stage one: qualitative interview findings

The initial qualitative analysis yielded 130 codes, which were categorized into 12 subcategories and 3 main categories. An overarching core theme was subsequently derived from these findings. The categories and subcategories are presented in Table 2.

Table 2.

Categories and subcategories extracted regarding the standards of the meta-accreditation system

Main category	Category	Subcategory
Pillars of the meta-accreditation (recognition) system	Structural standards of meta-accreditation	Structure and oversight of the accreditation system (P1, P2, P3, P5, P6, P9, P13)
		Stakeholder participation in standards development (P1, P6, P7)
		Accreditation assessors (P1, P2, P4, P6, P10, P12, P13)
		Record-keeping and results management (P3, P8, P11, P5)
	meta-accreditation process standards	Required resources for accreditation (P1, P3, P4, P6, P8, P9, P12, P13)
		Internal evaluation (P2, P10, P11)
		External evaluation (P1, P2, P4, P5, P7, P6, P12)
		Issuance of accreditation decisions (P1, P2, P6, P7, P9, P13)
	Social and ethical accountability standards	Accreditation cycles (P4, P7, P10)
		Ethical considerations in the accreditation process (P1, P6, P7, P11, P12)
		Public disclosure of results (P1, P2, P3, P5, P11)
		Conflict of interest in the accreditation process (P1, P5, P6, P10)

Participants emphasized that meta-accreditation standards should encompass the full scope of an accreditation system, including its design, implementation, decision-making processes, and ethical considerations. Specifically, qualitative findings contributed to three aspects of standards development: (1) identifying context-specific domains that required greater emphasis in the Iranian accreditation system, such as stakeholder participation and resource transparency; (2) modifying internationally derived standards to ensure feasibility within a centralized governance structure; and (3) clarifying terminology and operational expectations during the expert panel review. Thus, interviews served as a contextual adaptation mechanism rather than an independent source of standards generation.

Stage two: structure and common elements of recognition frameworks

The analysis of selected international recognition frameworks indicated that accreditation and recognition standards are primarily disseminated through official organizational documents rather than conventional academic publishing channels. Across all reviewed systems, including those developed by WFME¹, INQAAHE², ESG³, CHEA⁴, and APQR⁵, standards were structured as formal guidelines and recognition criteria made publicly available through institutional platforms. This reflects the applied and policy-oriented nature of accreditation systems, which are typically governed and operationalized by authoritative organizations rather than academic entities^9,10,12.

The analysis included six internationally recognized frameworks representing different geographical regions and accreditation contexts. These frameworks covered both general higher education quality assurance systems and medical education–specific accreditation recognition mechanisms. The analyzed systems included APQR (Asia-Pacific), ASG-QA (Africa), EQAR/ESG (Europe), CHEA (Americas), INQAAHE (international higher education), and WFME (medical education). Together, these frameworks provided a broad representation of approaches used internationally to evaluate and recognize accreditation bodies^8–13. The six analyzed frameworks represented both general higher education quality assurance systems (INQAAHE, CHEA, EQAR/ESG, APQR, and ASG-QA) and medical education–specific recognition mechanisms (WFME), allowing comparison of recognition approaches across different educational contexts (Table 3).

Table 3.

Selected recognition standard from continents (both medical education and higher education)

Continent/Field	Recognition System
Asia-Pacific	Asia Pacific Quality Register (APQR)(8)
Africa	African Standards and Guidelines for Quality Assurance (ASG-QA)(11)
Europe	European Quality Assurance Register for Higher Education (EQAR) (10)
Americas	Council for Higher Education Accreditation (CHEA)(9)
International	International Network for Quality Assurance Agencies in Higher Education (INQAAHE)(12)
Medical Education	World Federation for Medical Education (WFME) (13)

A total of 184 criteria/standards were extracted from the documents of the six recognition frameworks. Following conceptual analysis and synthesis, standards that were not applicable to a national-level meta-accreditation framework were excluded (n = 13), resulting in 171 remaining standards. These excluded items mainly related to functions beyond the scope of accreditation-body recognition, including cross-border quality assurance activities, networking functions, and specific organizational requirements of individual recognition systems.

Subsequently, 14 fully redundant standards were removed, leaving 157 unique standards. These standards were then grouped according to conceptual similarity and organized into three overarching domains and 19 sub-domains. Through further thematic synthesis, overlapping concepts were consolidated, resulting in 141 synthesized standards distributed across the 19 sub-domains (Table 4).

Table 4.

Comparative table of the number of standards and sub domain of the recognition systems used

Domain	APQR (8)	ASG-QA(11)	CHEA(9)	EQAR(10)	INQAAHE (12)	WFME (13)
Mission and objectives	1	12	1	1	3
Structure					2	2
Standards		4	1		5	4
Resources	1	2	1	1	2	2
Record keeping						2
Independence of the institution	1	3	1	1	1
Transparency	1		4		1	2
Ethics in accreditation			1		5
Conflict of interest			1		2	1
Public information					5
Quality assurance		3		1	1	1
Consultation and training	1	1				1
Self-assessment	1	2	1	1	2
External evaluation			1		5
Decision-making					5	5
Review and appeal	1		1		3	1
Feedback					1
Administrative procedures	1	7	5	1		6
Accreditation consequences						5
Total	8	34	18	6	43	32

The synthesis process demonstrated that although the international frameworks differed in terminology and level of detail, most criteria addressed three common dimensions: (1) governance and organizational capacity of accreditation bodies, (2) accreditation processes and decision-making mechanisms, and (3) accountability and continuous quality improvement. These common dimensions provided the conceptual foundation for developing the draft meta-accreditation standards.

Integration of qualitative findings resulted in contextual refinement of the internationally derived criteria. Comparison of the extracted international standards with expert perspectives identified several areas requiring adaptation to the Iranian accreditation context. In particular, experts emphasized that governance-related criteria should consider the characteristics of a centralized health education system, while maintaining principles of accountability, transparency, and operational autonomy. Consequently, some standards were modified, and additional elements related to stakeholder involvement, resource transparency, and contextual feasibility were incorporated into the draft framework.

Following the synthesis of international frameworks and contextual expert input, 58 preliminary meta-accreditation standards were generated across 14 sub-domains. These draft standards represented an integrated framework combining internationally recognized principles of accreditation-body evaluation with context-specific requirements identified through expert consultation. The resulting structure provided the basis for subsequent expert panel review and refinement in Stage Three. The overall synthesis process from international frameworks and qualitative findings is summarized in Figs. 1 and 2.

Fig. 1.

PRISMA-style flow diagram of standard identification, screening, consolidation, and validation process.

Fig. 2.

The domains of meta-accreditation standards resulting from the literature review and qualitative study.

Stage three: expert panel results

An expert panel was convened to review, refine, and contextualize the preliminary set of standards developed in Stage Two. The panel consisted of national experts in accreditation, quality assurance, and medical education policy, selected based on their experience in evaluation systems and governance structures within the Iranian higher education and health sectors. Panel members were provided with the draft framework, including domains, sub-domains, and associated standards, and were asked to evaluate each item in terms of clarity, relevance, and applicability within the national context. Structured feedback was collected through iterative review rounds, allowing experts to propose modifications, identify ambiguities, and suggest context-specific adaptations.

The expert panel review resulted primarily in qualitative refinements rather than substantial structural changes. The overall architecture of the framework—including the three domains and associated sub-domains—remained stable, reflecting strong alignment between international recognition frameworks and national expectations. Modifications focused on improving wording clarity, reducing ambiguity, and enhancing contextual relevance. In several cases, standards were rephrased to better align with national regulatory language and institutional practices. Minor adjustments were also made to ensure consistency in terminology and to avoid overlap between related standards.

A key contribution of the expert panel was the contextual adaptation of standards to the Iranian medical education and higher education system. Experts emphasized the importance of aligning the framework with existing governance mechanisms, regulatory requirements, and operational capacities of national accreditation bodies. These adaptations included clarification of accountability relationships between institutions and oversight bodies, alignment with national policy frameworks and regulatory expectations, and consideration of resource availability and implementation feasibility. As a result, the refined standards reflect not only international best practices but also the specific structural and policy context in which they are intended to be implemented.

Several standards were modified based on expert input to improve contextual relevance and feasibility. Regarding institutional independence, the international standard “The agency operates independently” was integrated with qualitative expert insights emphasizing the need for decision-making free from internal pressure, resulting in the adapted standard: “The accrediting body maintains independence in issuing accreditation decisions, ensuring neutrality and absence of conflicts of interest” (Standard 2-4-3). Standards related to stakeholder participation were expanded to include students, teaching hospital representatives, and relevant professional associations, reflecting the structure of the Iranian medical education system (Standard 1-2-3). Expert concerns regarding financial and administrative burden led to the inclusion of a standard emphasizing efficient use of resources and avoidance of unnecessary costs during accreditation processes (Standard 1-4-3).

Following expert consensus, the preliminary 58 standards were refined into a final set of 51 standards organized within three domains and 13 sub-domains. This reduction resulted from merging four overlapping standards and removing three standards that were considered insufficiently measurable or not applicable to the national meta-accreditation context.

Overall, the expert panel process primarily served as a mechanism for contextual refinement rather than initial generation of standards. While the core structure of the framework was largely derived from international recognition systems, expert input ensured alignment with national governance structures, regulatory expectations, and operational realities of the Iranian medical education system. The modifications introduced through this process mainly enhanced clarity, feasibility, and contextual relevance, underscoring the importance of adapting meta-accreditation frameworks to local contexts for effective implementation.

The characteristics of the experts involved in this process are summarized below.

Stage four: national survey results

In the final stage, the refined set of standards was subjected to quantitative evaluation to assess the level of expert agreement. A structured questionnaire was developed based on the finalized 51 standards and distributed to a broader group of stakeholders with expertise in accreditation, quality assurance, and medical education. Participants were asked to evaluate each standard across three predefined criteria: necessity, transparency, and feasibility. Responses were recorded using a Likert scale, and agreement levels were calculated for each criterion.

A total of 203 experts participated in this stage. Participants included policymakers, accreditation experts, faculty members, and quality assurance specialists with experience in higher education and medical education systems.

Across the three evaluation criteria, the majority of standards demonstrated high levels of stakeholder agreement. Forty-five of the 51 standards (88.2%) achieved agreement levels above 80% across all three criteria. Necessity received the highest level of agreement, with all standards exceeding the predefined threshold. This indicates strong consensus among participants regarding the importance of establishing a structured national mechanism for evaluating accreditation bodies. Transparency and feasibility showed slightly greater variability compared to necessity. However, this variation primarily reflected implementation-related considerations rather than disagreement with the conceptual foundations of the standards.

Analysis at the domain level revealed consistent patterns of agreement across the three main domains of the framework. Standards related to accountability and quality improvement demonstrated particularly high levels of agreement across all three evaluation criteria. This suggests that stakeholders place strong emphasis on transparency, monitoring mechanisms, feedback systems, and continuous improvement as essential components of a credible meta-accreditation system. In contrast, standards related to operational and structural aspects showed slightly more variability, particularly in feasibility scores. This likely reflects differences in perceived resource availability, institutional capacity, and implementation readiness across contexts.

Although overall agreement was high, a small number of standards demonstrated comparatively lower scores, particularly in the feasibility dimension. These standards were generally associated with resource-intensive evaluation processes, complex governance structures, and requirements for extensive stakeholder engagement. Despite lower feasibility ratings, these standards maintained acceptable levels of agreement and were retained due to their conceptual importance and alignment with international best practices Tables 5–8.

Table 6.

Demographic characteristics of the people present on the expert panel

	Career History			Education			Member of Accreditation Secretariats	Member of National Accreditation Commission	Member of Accreditation Secretariats
	15-20	20-25	>25	MD	MD/ PhD	PhD
Male	1	1	2	-	-	4	2	2	1
Female	-	1	1	1	1	-			1

Table 7.

The demographic and professional characteristics of participants in consensus

Work Experience	Gender	Supreme Council for Planning	Council for Development	Secretariat of General Medical Education	Secretariat of Basic Medical Sciences	Secretariat of Specialty Education	Secretariat of Dentistry Education	Secretariat of Pharmacy Education	Secretariat of Hospital Accreditation	External Evaluator (No Membership)	Total
10-15	Female	0	0	2	0	1	0	2	2	10	17
	Male	0	0	2	0	0	0	1	1	10	14
15-20	Female	0	0	0	1	0	0	0	0	5	6
	Male	1	0	1	1	0	1	0	0	4	8
> 20 years	Female	0	1	1	0	5	0	0	1	10	18
	Male	3	2	0	6	1	3	2	0	10	27
Total	Female	0	1	3	1	6	0	2	3	25	41
	Male	4	2	3	7	1	4	3	1	24	49
Total		4	3	6	8	7	4	5	4	49	90

Table 5.

Comparative table of the scopes and standards of Iran's identification systems and meta-accreditation system

Scope	ASGQA	EQAR	APQR	CHEA	WFME	INQAAHE	IRAN
Mission and purpose	12	1	1	1		3	2
Structure					2	2	3
Standards	4			1	4	5	7
Resource Management	2	1	1	1	2	2	3
Internal Evaluation	2	1	1	1		2	2
External Evaluation				1		5	10
Consultation and Training	1		1		1		2
Decision Making					5	5	10
Feedback and Monitoring						1	3
Review and appeal			1	1	1	3	2
Quality Assurance	3	1			1	1	2
Accountability and Discipline							3
Record Keeping					2		2
Institutional Independence	3	1	1	1		1	The standards of these domains have been included in other domains of Iran's identification system.
Transparency			1	4	2	1
Ethics in Accreditation				1		5
Conflict of Interest				1	1	2
Public Information						5
Administrative Procedures	7	1	1	5	6
Accreditation Consequences					5

Table 8.

Percentage of agreement for each standard in the three dimensions

Agreement percentage
standard	practicality	Necessity	transparency	standard	practicality	Necessity	transparency	standard	Practicality	necessity	transparency
3-1-1	92%	94%	86%	2-1-1	91%	94%	82%	1-1-1	91%	90%	88%
3-1-2	88%	92%	80%	2-1-2	87%	88%	83%	1-1-2	88%	92%	82%
3-2-1	82%	92%	80%	2-2-1	89%	91%	86%	1-2-1	87%	94%	86%
3-2-2	89%	91%	81%	2-2-2	90%	92%	88%	1-2-2	89%	93%	89%
3-2-3	87%	92%	87%	2-2-3	88%	92%	86%	1-2-3	84%	93%	76%
3-3-1	93%	93%	91%	2-2-4	82%	93%	84%	1-3-1	81%	92%	86%
3-3-2	92%	93%	91%	2-2-5	88%	90%	79%	1-3-2	83%	91%	81%
				2-2-6	92%	94%	92%	1-3-3	89%	91%	87%
				2-2-7	91%	90%	89%	1-3-4	94%	92%	87%
				2-2-8	92%	93%	92%	1-3-5	91%	93%	89%
				2-2-9	82%	90%	84%	1-3-6	89%	89%	89%
				2-2-10	87%	91%	83%	1-3-7	83%	88%	80%
				2-3-1	90%	90%	86%	1-4-1	79%	87%	80%
				2-3-2	92%	90%	82%	1-4-2	78%	89%	79%
				2-4-1	89%	92%	82%	1-4-3	82%	88%	76%
				2-4-2	89%	93%	79%
				2-4-3	82%	92%	82%
				2-4-4	91%	93%	87%
				2-4-5	89%	94%	82%
				2-4-6	86%	89%	80%
				2-4-7	90%	92%	87%
				2-4-8	91%	91%	89%
				2-4-9	88%	89%	86%
				2-4-10	89%	90%	84%
				2-5-1	92%	93%	84%
				2-5-2	84%	91%	83%
				2-5-3	78%	90%	79%
				2-6-1	87%	91%	81%
				2-6-2	88%	89%	81%

Based on the quantitative evaluation, all 51 standards met the predefined acceptance criteria and were retained in the final framework. No additional standards were removed at this stage. The results of this phase confirmed the robustness, relevance, and overall acceptability of the proposed meta-accreditation framework among a broad group of stakeholders.

The findings of the quantitative validation indicate a high level of consensus on the proposed standards, particularly regarding their necessity and conceptual relevance. The slightly lower agreement observed in feasibility highlights the importance of considering contextual constraints—such as resource availability and institutional capacity—during implementation. These findings reinforce the need for phased implementation strategies and context-sensitive adaptation when operationalizing meta-accreditation systems. Overall, the results support the validity and applicability of the developed framework as a foundation for establishing a national meta-accreditation system in medical education.

Following the development and validation of the standards through the national survey and expert panel review, a pilot implementation was conducted in one accreditation secretariat under the Ministry of Health and Medical Education. The pilot aimed to assess the feasibility, transparency, and applicability of the 51 standards in a real-world accreditation setting. The implementation process involved applying the standards to evaluate the secretariat’s operations, procedures, and decision-making processes. Feedback from the pilot implementation was collected and used to identify any practical challenges or domains requiring further refinement. Subsequently, the finalized standards were submitted to the National Accreditation Commission—the highest decision-making body for accreditation in Iran’s medical education system—for formal approval. The Commission reviewed the standards alongside the pilot implementation findings and approved the framework for national adoption. This approval represents the official endorsement of the meta-accreditation standards as the national benchmark for evaluating accreditation bodies in Iran’s medical education system. The pilot implementation and subsequent approval demonstrate the framework’s practical utility and readiness for broader implementation across all accreditation secretariats under the Ministry of Health and Medical Education.

The final version of the standards, after incorporating participant feedback, includes 51 standards organized into 3 domains and 13 sub-domains. The domains are: Structure and formality (4 sub-domains, 15 standards); Accreditation Processes (6 sub-domains, 22 standards); and Accountability and Quality Improvement (3 sub-domains, 14 standards). The complete standards are presented in Table 9.

Table 9.

Standards of Iran's Meta-Accreditation System

Discussion

This study developed the first national meta-accreditation standards for Iran by integrating global benchmarks with localized expert insights. Our four-stage standards development and consensus-building process, synthesizing input from six international recognition bodies and diverse domestic stakeholders, resulted in a framework of 51 standards across three core domains: (1) Structure and formality, (2) Accreditation Processes, and (3) accountability and Quality Improvement. The high agreement rates in the national survey, particularly in the dimension of necessity (87–94%), underscore both the validity and relevance of these standards to the Iranian context.

Our findings reveal a significant structural alignment between the Iranian meta-accreditation standards and international frameworks established by WFME, INQAAHE, and CHEA^9,12,13. The three core domains identified—Structure and Eligibility, Accreditation Processes, and Responsiveness and Quality Improvement—resonate with the organizational logic of these international recognition systems. This convergence suggests the existence of universal tenets for effective meta-accreditation that transcend national contexts. For instance, the emphasis on transparency, structured decision-making, and ethical conduct emerged as foundational elements in both global standards and our expert interviews, highlighting their essential role in legitimizing accreditation bodies.

However, structural similarity in domains does not necessarily equate to conceptual or functional alignment. While the Iranian framework shares domain-level organization with international systems, the specific content and emphasis of individual standards reflect important contextual adaptations. The high level of expert consensus on the necessity of these standards (87-94%) suggests that the framework has been effectively tailored to address the specific governance and regulatory context of Iran’s medical education system.

A key contribution of this study is the systematic contextual adaptation of international meta-accreditation principles to the Iranian setting. Unlike a direct translation or superficial application of international frameworks, our approach integrated expert qualitative insights with international benchmarks to produce standards that are both globally informed and locally relevant.

A salient example is the treatment of institutional independence. While this is a standalone domain in five of the six international frameworks reviewed^8–13, our experts, reflecting Iran’s state-centric accreditation landscape, advocated for its integration into other domains such as mission, governance, and decision-making. This adaptation represents a pragmatic contextualization rather than a compromise of the core principle. In a system where accreditation bodies operate under the Ministry of Health and Medical Education, maintaining institutional independence in decision-making while acknowledging the broader governance structure required a nuanced approach. The resulting standards address independence through specific procedural requirements (e.g., Standard 2-4-3: “The accrediting body maintains independence in issuing accreditation votes, ensuring decisions are made neutrally and free from conflicts of interest”) rather than through a separate structural domain.

This finding aligns with Gandomkar et al.²⁰, who emphasized that the successful implementation of international standards hinges on their adaptation to local realities. Similarly, Taber et al.⁶ argued that accreditation systems must be “fit for purpose,” accounting for the specific cultural, regulatory, and institutional contexts in which they operate.

Beyond its immediate impact on educational quality, the meta-accreditation framework has broader implications for health system governance. By ensuring the credibility and consistency of accreditation decisions, a robust meta-accreditation system can strengthen institutional trust, enhance regulatory coherence, and improve the legitimacy of quality assurance mechanisms—all of which are central to health systems performance and patient safety⁴.

The high consensus on standards related to accountability and quality assurance (92–94% agreement) suggests a strong collective recognition among Iranian stakeholders of the need to enhance the credibility and public trust of accreditation outcomes. By mandating self-evaluation, periodic reporting, and public disclosure of decisions, these standards aim to foster a culture of continuous quality improvement and social accountability within accrediting bodies themselves. This is particularly important in the Iranian context, where public trust in regulatory institutions has been identified as a concern¹⁸.

The development of a meta-accreditation framework in a state-centric system like Iran’s raises important structural tensions that merit consideration. First, the potential overlap between regulatory and evaluative functions must be addressed. When the same ministry that oversees accreditation bodies also evaluates them, questions of independence and objectivity arise. Our framework addresses this through standards requiring independent decision-making processes (Standard 2-4-3), transparent procedures (Standard 2-4-6), and mechanisms for appeal and review (Standards 2-6-1 and 2-6-2).

Second, constraints on institutional autonomy in a centralized system may affect the willingness of accreditation bodies to engage in critical self-evaluation. The standards requiring regular self-evaluation of accrediting bodies’ performance (Standard 3-1-1) and external monitoring of their activities (Standard 2-2-9) are designed to counteract this tendency by embedding accountability mechanisms within the system itself.

Third, the balance between state oversight and professional self-regulation represents an ongoing tension. While the Iranian system is necessarily state-centric, the inclusion of diverse stakeholders—including experts, professional associations, teaching hospitals, and students—in accreditation processes (Standard 1-2-3) reflects an effort to incorporate professional and societal input into what might otherwise be a purely bureaucratic exercise.

The strengths of this study lie in its rigorous methodological approach and strong stakeholder engagement. The four-stage process ensured that the final framework was informed by multiple sources of evidence: international best practices, expert qualitative insights, panel deliberation, and broad stakeholder consensus. The high response rate to the national survey (44.3%) and the consistency of findings across stakeholder groups enhance the credibility of the framework.

The classification of all 51 standards as mandatory based on >80% agreement on the necessity dimension indicates that stakeholders view these standards as essential rather than aspirational. This suggests a readiness within the Iranian medical education community to embrace a robust meta-accreditation system.

“A key strength of this study is the successful pilot implementation of the standards in an operational accreditation setting, followed by formal approval by the National Accreditation Commission. This progression from development to validation to pilot testing to formal approval demonstrates the framework’s practical utility and enhances the credibility of the study’s recommendations”²¹.

This study has several limitations. The qualitative sample of 13 national experts, while appropriate for achieving theoretical saturation, may reflect the perspectives of individuals deeply embedded within the existing system, potentially underrepresenting more critical external viewpoints such as those of faculty members or students who are primarily subjects of accreditation rather than its agents. The national survey, despite a response rate of 44.3%, is susceptible to non-response bias, and the method used to calculate percentage of agreement—summing the top two response categories (e.g., “fully achievable” and “partially achievable”) and dividing by total responses—may have overestimated the level of consensus. While this approach was chosen to provide a pragmatic measure of at least partial acceptability, it does not distinguish between strong and weak endorsement. The full distribution of responses across all three options is provided in Supplementary Table 1 to allow readers to assess the degree of consensus beyond the collapsed categories. Additionally, while this study establishes robust content validity and expert consensus, it does not demonstrate the actual efficacy or impact of these standards in improving the quality of accreditation decisions or educational outcomes, and real-world implementation may face challenges including the need for significant resource allocation (financial, human, technical), potential resistance to change from established accreditation bodies, and the complexity of operationalizing certain standards within Iran’s specific bureaucratic context. Despite these limitations, this study provides a validated, contextually-relevant framework for meta-accreditation in Iranian medical education, with its strength lying in its dual foundation of rigorous adherence to international best practices and robust grounding in national expert consensus, providing a clear roadmap for enhancing the consistency, transparency, and credibility of Iran’s accreditation system. Importantly, the framework has undergone pilot implementation in one accreditation secretariat and received formal approval from the National Accreditation Commission, providing a strong foundation for national implementation. Based on the successful development, validation, pilot implementation, and formal approval of the meta-accreditation standards, the National Accreditation Commission has already approved the standards as the national benchmark for evaluating accrediting bodies under the Ministry of Health and Medical Education, and we recommend the formal dissemination of the approved standards to all accreditation secretariats and relevant stakeholders across the medical education system. Building on the successful pilot implementation in one accreditation secretariat, we recommend a phased expansion to additional accreditation bodies, allowing for iterative refinement based on implementation experience while minimizing disruption to ongoing accreditation activities. Establishing a dedicated meta-accreditation committee with appropriate expertise and independence is recommended to oversee the evaluation of accreditation bodies and ensure consistent application of the standards. Creating a formal feedback mechanism would further support continuous improvement of the standards based on implementation experience, stakeholder input, and emerging international developments, with regular reviews to ensure ongoing alignment with global best practices. Additionally, providing training and professional development opportunities for accreditation body staff, external evaluators, and committee members would enhance their understanding of the meta-accreditation standards and their application. Regarding research, longitudinal studies examining the impact of the meta-accreditation framework on the quality, consistency, and transparency of accreditation decisions would be valuable, as would studies exploring the financial and operational models required for sustained implementation, including cost-benefit analyses and resource requirements for different implementation approaches. Investigating the perceptions of accreditation body staff, evaluated institutions, and other stakeholders regarding the meta-accreditation process would help identify domains for improvement and enhance stakeholder engagement. Comparative studies examining meta-accreditation approaches in other countries with state-centric systems could identify best practices and contextual adaptations that may inform ongoing refinement of the Iranian framework. Further psychometric studies to assess the reliability and validity of the standards as measurement tools, including inter-rater reliability studies and criterion-related validity assessments, as well as research examining the relationship between meta-accreditation and broader health system outcomes including workforce quality, patient safety, and health service delivery, also represent important avenues for future inquiry. The four-stage model for developing meta-accreditation standards applied in this study—combining qualitative expert interviews, systematic literature review, expert panel deliberation, national stakeholder survey, pilot implementation, and formal approval—offers a robust and replicable methodology for other countries seeking to establish their own meta-accreditation systems. The resulting 51 standards, organized across three domains (Structure and formality, Accreditation Processes, and Accountability and Quality Improvement), provide a comprehensive framework that can be adapted to various national contexts. The methodology and findings are particularly valuable for nations with governmental oversight of accreditation, offering a tested pathway for establishing or strengthening meta-accreditation systems within state-centric governance structures; for countries developing accreditation systems, providing a blueprint for building quality assurance mechanisms that meet international standards while addressing local contextual needs; for medical education systems, demonstrating how international recognition frameworks such as WFME can be contextualized for national implementation; and for low- and middle-income countries, presenting a resource-conscious approach to developing and validating quality assurance standards that balances international benchmarks with local feasibility. The successful pilot implementation and formal approval of the framework by Iran’s National Accreditation Commission demonstrate the practical utility of this approach and provide confidence that similar pathways can be effective in other contexts. As accreditation continues to play a central role in assuring educational quality worldwide, this study offers a valuable contribution to the global discourse on quality assurance governance and system legitimacy.

Methods

This study was conducted within the context of the Iranian medical education system under the Ministry of Health and Medical Education (MOHME), where accreditation processes are implemented across multiple health professions disciplines.

A multi-stage standards development and consensus-building design was employed to develop national meta-accreditation standards for educational accreditation bodies in Iran. The study was conducted between 2023 and 2024 and used a sequential mixed-methods approach specifically designed for standards development. In contrast to conventional exploratory or explanatory mixed-methods designs, this approach integrated qualitative and quantitative methods through a structured developmental process, in which evidence from different sources was progressively synthesized to generate, refine, and validate a context-specific standards framework^22,23.

The methodology consisted of four sequential stages: (1) qualitative expert interviews to explore contextual requirements and identify key considerations relevant to meta-accreditation; (2) systematic identification and document analysis of international recognition frameworks to generate an initial pool of candidate standards; (3) expert panel review to assess, refine, and contextualize the proposed standards; and (4) a national stakeholder survey to evaluate the applicability and acceptance of the developed standards.

The standards framework was structured hierarchically into three levels: domains, sub-domains, and standards. The evaluation criteria of necessity, practicality, and transparency were defined as assessment dimensions applied to each standard during the validation phase and were not considered structural elements of the framework.

Integration of evidence sources was conducted through an iterative adaptation process. Standards identified from international recognition frameworks were systematically compared with themes derived from qualitative interviews using a thematic mapping approach. Standards demonstrating conceptual alignment were retained, whereas those requiring contextual modification were revised according to characteristics of the Iranian accreditation environment. Additional standards were considered when specific contextual requirements emerged from expert perspectives. This process aimed to ensure that the final framework represented a contextually adapted model rather than a direct adoption of international recognition frameworks.

The overall process of standards identification, refinement, and validation is presented in Fig. 3.

Fig. 3.

Sub domains and standards in the meta-accreditation system developed by expert consensus.

Stage one: qualitative interview with iranian accreditation experts

A qualitative approach was employed to explore context-specific considerations related to the development of meta-accreditation standards within the Iranian medical education system. Purposive sampling, supplemented by snowball sampling, was used to recruit national experts with substantial experience in accreditation policy, governance, and implementation. The inclusion criteria were: at least five years of experience in accreditation policy-making, planning, or implementation; membership in the National Accreditation Commission; experience with internal and external evaluation processes; and involvement in the development of accreditation standards or related regulations in Iran. Thirteen national-level accreditation experts participated in the study. Sampling continued until data saturation was achieved, defined as the point at which no new codes or concepts emerged from two consecutive interviews. The adequacy of the sample was further supported by the inclusion of experts representing diverse roles within the accreditation system, including governance, policy development, implementation, and evaluation. The only exclusion criterion was unwillingness to participate. Participant characteristics are presented in Table 1.

Data were collected through in-depth semi-structured interviews lasting 35–65 min. Interviews were conducted either face-to-face or online via Google Meet or Sky room according to participants’ preferences. The interview guide was developed based on the study objectives, relevant accreditation literature, and key conceptual domains related to accreditation governance. The guide was reviewed and pilot-tested with two experts, and minor refinements were made after the first three interviews to improve clarity and comprehensiveness. The final interview guide is provided in Supplementary File 1. All interviews were conducted in Farsi and began with general questions regarding participants’ experiences and roles in accreditation, followed by open-ended questions addressing issues relevant to the development of meta-accreditation standards, including mission and functions of accreditation systems; governance and organizational structure; accreditation processes and evaluation mechanisms; and resource requirements and accountability. Interviews were audio-recorded with participants’ informed consent and transcribed verbatim. To minimize interviewer bias, neutral probing techniques were used, and verbal or non-verbal reinforcement of specific viewpoints was avoided.

Interview transcripts were analyzed using inductive qualitative content analysis based on the approach described by Graneheim and Lundman²⁴. Two researchers with expertise in medical education research and qualitative methodology independently coded the transcripts. Initial codes were compared, and discrepancies were discussed until consensus was reached. Cohen’s kappa coefficient was calculated to assess coding agreement (κ = 0.82), indicating strong agreement. Remaining disagreements were resolved through discussion and, when necessary, consultation with a third researcher experienced in accreditation systems. The rigor of the qualitative analysis was ensured according to Lincoln and Guba’s criteria²⁵. Strategies used to enhance trustworthiness included prolonged engagement with the data, researcher triangulation, member checking with selected participants, and external audit by an independent qualitative research expert. The findings from this qualitative phase were subsequently integrated with the results of the international document analysis (Stage Two) to support contextual adaptation and refinement of the preliminary standards.

Stage two: international recognition framework identification and document analysis

To identify existing standards related to the recognition of accrediting bodies, a structured search was conducted across multiple academic databases, including Scopus, Web of Science, PubMed, ERIC, and the Cochrane Library, as well as Iranian databases (SID, Magiran, and Civilica). The search was performed between October 2023 and January 2024. The search strategy combined four conceptual domains: meta-accreditation and recognition concepts, external quality assurance agencies, standards and frameworks, and medical or higher education accreditation contexts. The search strategy was initially developed for Scopus and adapted for other databases: (“meta-accreditation” OR “meta-evaluation” OR recognition OR “external quality assurance” OR “quality assurance agency*“ OR “accreditation body*“) AND (standard* OR framework* OR criterion* OR guideline*) AND (accreditation OR accrediting OR “medical education” OR “higher education”). Despite the breadth of the search, only a limited number of peer-reviewed publications directly addressed recognition standards for accrediting bodies, indicating a gap in the literature and supporting the need for document-based analysis.

Because the term “meta-accreditation” is not consistently used in international literature, this study operationally defined it as equivalent to the recognition or external evaluation of accreditation bodies. This conceptual alignment is consistent with global quality assurance practices, where recognition systems are widely used to assess the legitimacy, credibility, and performance of external quality assurance agencies^10,26,27.

In addition to database searching, official documents published by international quality assurance and accreditation organizations were systematically reviewed. These included standards, guidelines, recognition criteria, and policy documents. The selection of international frameworks was purposive and guided by three predefined criteria: geographic representation (Asia-Pacific, Africa, Europe, and the Americas); scope of application (general higher education and medical/health professions education); and functional focus on evaluation and recognition of accreditation bodies. Based on these criteria, six major international frameworks were selected:

• International Network for Quality Assurance Agencies in Higher Education (INQAAHE)¹²

• Council for Higher Education Accreditation (CHEA)⁹

• African Standards and Guidelines for Quality Assurance in Higher Education (ASG-QA)¹¹

• Asia-Pacific Quality Register (APQR)⁸

• European Quality Assurance Register (EQAR)²⁸, using the Standards and Guidelines for Quality Assurance in the European Higher Education Area (ESG)²⁹

• World Federation for Medical Education (WFME)³⁰

During the selection process, the HAQAA initiative was initially reviewed; however, ASG-QA was selected because it provides operational standards. Similarly, EQAR was treated as the recognition system, while ESG was considered the underlying standards framework.

Standards and criteria were extracted through systematic review of the selected documents. Each item was recorded in a structured extraction matrix including the source framework, original wording, conceptual category, and relevance to a national meta-accreditation system. The extraction process was conducted iteratively, with repeated review of documents to ensure consistency and completeness. A comparative thematic synthesis approach was used to analyze the extracted standards. The process included initial screening to exclude standards not aligned with accreditation-body evaluation; de-duplication to remove conceptually identical criteria; categorization into domains and sub-domains based on conceptual similarity; conceptual synthesis to merge overlapping standards into broader meta-accreditation constructs; and refinement to review for clarity, coherence, and applicability. This approach is consistent with established qualitative synthesis methods used in health and education research²⁴. Findings from Stage One were integrated during the refinement phase. Extracted standards were compared with themes derived from expert interviews. Relevant qualitative evidence was identified from coded interview data, and where necessary, standards were modified to improve contextual relevance, feasibility, and clarity. This ensured alignment between international best practices and national requirements. The overall process of identification, screening, selection, extraction, and synthesis was summarized using a PRISMA-inspired flow diagram (Fig. 1).

Third stage: expert panel to refine draft standards

Six experts in medical education and accreditation were purposively selected based on membership in national accreditation bodies, experience in developing accreditation standards, and experience as external evaluators. Seven hybrid (in-person/online) sessions were conducted, each lasting at least two hours. Sessions were facilitated, recorded, and documented. Each standard was evaluated based on four criteria: necessity, relevance, measurability, and feasibility. Standards not meeting all criteria were excluded or revised. Consensus was achieved primarily through discussion. When needed, voting was used with an 80% agreement threshold. Standards were iteratively reviewed, merged, and refined until agreement was reached. The 58 draft standards were refined through expert panel review, during which overlapping items were merged, redundancies were eliminated, and some standards were revised or removed based on expert consensus, resulting in a final set of 51 standards, 13 subdomains and 3 domains.

Fourth stage: online national survey to assess consensus

The finalized draft standards were assessed in a national survey to determine consensus on their practicality, necessity, and transparency. The survey was distributed to 203 stakeholders, including members of accreditation secretariats and committees, external evaluators, and examination board members from various disciplines (medicine, dentistry, pharmacy, and basic sciences). A comprehensive list of eligible participants was obtained from the national accreditation secretariats and official MOHME records. The sampling frame comprised all individuals who had served in these roles within the Iranian medical education accreditation system during the past five years. Each standard was evaluated across three dimensions using a three-point Likert-type scale: practicality (fully achievable, partially achievable, not achievable); transparency (completely clear, requires revision, unclear); and necessity (absolutely essential, beneficial but not critical, not necessary). The survey was administered online using the Porsline platform, a web-based survey tool designed for academic research. The instrument also included open-ended text boxes for each standard to collect qualitative feedback and suggestions for revision. Agreement percentages³¹ were calculated for each dimension using the following formula:

$$\text{Percentage}\text{of}\text{agreement}=\frac{\text{Sum}\text{of}\text{responses}2\text{and}3}{\text{Total}\text{responses}}\times 100$$

The percentage of agreement was calculated for each standard and dimension by combining the positive responses (e.g., ‘fully achievable’ and ‘partially achievable’ for practicality; ‘completely clear’ and ‘requires revision’ for transparency; ‘absolutely essential’ and ‘beneficial but not critical’ for necessity) and dividing by the total number of responses. This approach, commonly used in consensus studies³¹, was chosen to provide a pragmatic measure of at least partial acceptability, rather than only measuring strong endorsement. The term “agreement” in this context refers to the proportion of respondents who found the standard at least partially acceptable or clear, which is a more feasible threshold for implementation purposes than requiring full endorsement. This approach may overestimate agreement, as it includes partially positive responses; therefore, full response distributions are also reported in Supplementary Table 2. A threshold of ≥70% agreement was used for standard retention. This consensus approach was selected because the primary objective was to assess stakeholder agreement and implementation feasibility rather than to develop or validate a psychometric measurement instrument. Evidence supporting the content relevance and applicability of the standards was obtained through multiple complementary processes, including expert review, iterative revision, qualitative feedback analysis, and national stakeholder evaluation. Transparency scores between 70% and 79% triggered revision, while standards achieving ≥80% agreement on necessity were classified as mandatory. Free-text suggestions (n = 121) were analyzed using qualitative content analysis. Two researchers independently coded the comments, categorized them by the standard they addressed, and identified recurring themes. Suggestions that were raised by at least three participants were flagged for consideration in revisions. Following the survey, six standards with transparency scores between 76–79% were revised based on participant feedback; the revised versions were re-surveyed and accepted by the expert panel from Stage Three.

Following completion of the consensus and national validation stages, the finalized standards were piloted in one medical education accreditation secretariat affiliated with MOHME. The pilot aimed to assess operational feasibility, clarity of standards, and potential implementation challenges. The secretariat conducted a self-assessment using the developed standards, followed by structured feedback from responsible officers and members of the accreditation body. The feedback was reviewed by the research team and considered in confirming the applicability of the final framework. Subsequently, the standards were submitted to the National Accreditation Commission for review and approval²¹.

Ethical considerations

Ethical approval was obtained from the National Center for Strategic Research in Medical Education (Nasr) (ID: IR.NASRME.REC.1402.044) and the Ethics Committee of Isfahan University of Medical Sciences (ID: IR.MUI.REC.1402.019). Both approvals covered all four stages of the study. Participation was voluntary, and informed consent was obtained from all participants with assurances of anonymity and confidentiality.

Author contributions

N.Y. and T.Ch. Conceptualized the study and designed the methodology. T.S.A.R.Kh. conducted the interviews and performed the data analysis. T.S.A.R.Kh. and N.Y. conducted the initial literature reviews. T.S.A.R.Kh., N.Y. and T.Ch. Summarized and scoped the initial structure. T.S.A.R.Kh., N.Y. and T.Ch. Contributed to data analysis and provided critical revisions to enhance the manuscript. A.M. and M.Z. reviewed the draft and suggested substantive improvements. All authors approved the final version for submission.

Data availability

The data that support the findings of this study are available on request from the corresponding author.

Declarations

Competing interests

The authors declare no competing interests.

Supplementary information

The online version contains supplementary material available at https://doi.org/10.1038/s44401-026-00150-8.