Identifying and Prioritizing the Effective Factors on Establishing Accreditation System in Tehran Hospitals affiliated with the Social Security Organization in Tehran, 2016

Document Type: Articles

Authors

1 PhD candidate in Health care services management, Science and Research Branch, Islamic Azad University, Tehran, Iran

2 Associate Professor ,Department of Health Services Management, Science and Research Branch, Islamic Azad University, Tehran, Iran

3 Professor ,Department of Health Management, Iran University of Medical Sciences, Tehran, Iran

Abstract

Introduction: There is much less attention to the structural, processing, and functionalstandards in accreditation of health care organizations. The purpose of this study was todetermine and prioritize the factors affecting the implementation of accreditation system inhospitals affiliated with the Social Security Organization in Tehran in 2016.Methods: This is a cross‐sectional quantitative study conducted among hospital staffrecruited through census sampling. To collect the data, a researcher-made questionnaireconsisting of 24 factors was designed using hierarchical analysis method. After collecting thequestionnaires, studying criteria and factors were analyzed and prioritized based on AnalyticHierarchy Process model (AHP) and inconsistency ratio (ICR) using the Super DecisionsSoftware. To determine whether there is a significant difference between the respondents’answers, we performed one-sample t-test using SPSS software.Results: According to the findings, 49 out of the 170 participants were male and the restwere female. In order to investigate the factors affecting the establishment of the accreditation system, we the ranking of factors showed that the output criterion with the weight of 0.443 had the highest priority, and then the criterion of the structure with a weight of 0.279 and the process criterion with a weight of 0.278 in the next priorities were placed.Conclusion: The findings of the present study, scientifically through the review of documentsand evidence, as well as their integration with the opinions of domestic experts, resulted inachieving an effective model for establishing accreditation based on structural, processing,and output standards and considering the weight of each group of standards. The factorsaffecting the accreditation system take into account the constraints on the content andimplementation process of the current accreditation program and complements the existinggaps by adding the dimensions and components required. Using a simple, comprehensiveand efficient approach, it is possible to provide an opportunity to improve the status ofaccreditation and quality of services in hospitals of Tehran’s social security hospitals.Keywords: Accreditation, Donabedian Model, Hospital, Social Security

  1. Kalhor R, Amini S, Sokhanvar M, Lotfi F, Sharifi M, Kakemam E. Factors affecting the technical efficiency of general hospitals in
  2. Iran: data envelopment analysis. J Egypt Public Health Assoc. 2016;91(1):20-5.doi: 10.1097/01. epx.0000480717.13696.3c.
  3. Lotfi F, Kalhor R, Bastani P, Zadeh NS, Eslamian M, Dehghani MR, et al. Various indicators for the assessment of hospitals’ performance status: differences and similarities. Iranian Red Crescent
  4. medical journal. 2014;16(4). doi: 10.5812/ ircmj.12950 .
  5. Kakeman E, Forushani AR, Dargahi H. Technical efficiency of hospitals in Tehran, Iran. Iranian journal of public health. 2016;45(4):494.
  6. Tsai TC, Joynt KE, Orav EJ, Gawande AA, Jha AK. Variation in surgical-readmission rates and quality of hospital care. N Engl
  7. J Med. 2013;369(12):1134-42. doi; 10.1056/ nejmsa1303118.
  8. Aronsson H, Abrahamsson M, Spens K. Developing lean and agile health care supply chains. Supply chain management: An
  9. international journal. 2011;16(3):176-83.doi; 10.1108/13598541111127164.
  10. Mohamed N, Gabr H. Develop accreditation standards for nursing departments at Mansoura University Hospital. J Educ Practice. 2013;4(7):37-48.
  11. Grigoroudis E, Orfanoudaki E, Zopounidis C. Strategic performance measurement in a healthcare organisation: A multiple criteria
  12. approach based on balanced scorecard. Omega. 2012;40(1):104-19. Doi: 10.1016/j. omega.2011.04.001.
  13. Alkhenizan A, Shaw C. Impact of accreditationon the quality of healthcare services: a systematic review of the literature. Ann Saudi Med. 2011;31(4):407-16.doi: 10.4103/0256-4947.83204 .
  14. Shaw CD, Groene O, Botje D, Sunol R, Kutryba B, Klazinga N, et al. The effect of certification and accreditation on quality management in 4
  15. clinical services in 73 European hospitals. Int J Qual Health Care. 2014;26(suppl_1):100-7.
  16. Schmaltz SP, Williams SC, Chassin MR, Loeb JM, Wachter RM. Hospital performance trends on national quality measures and the association with Joint Commission accreditation. J Hosp
  17. Med. 2011;6(8):454-61. Doi: 10.1002/jhm.905.
  18. Touati N, Pomey M-P. Accreditation at a crossroads: are we on the right track? Health Policy. 2009;90(2-3):156-65.
  19. Braithwaite J, Westbrook J, Johnston B, Clark S, Brandon M, Banks M, et al. Strengthening organizational performance through
  20. accreditation research-a framework for twelve interrelated studies: the ACCREDIT project study protocol. BMC Res Notes. 2011;4(1):390.
  21. Doi: 10.1186/1756-0500-4-390.
  22. Waljee N, McAteer S, Nickerson V, Khalfan A. Using the accreditation journey to achieve global impact: UHN’s experience at the Kuwait Cancer Control Center. Healthcare quarterly
  23. (Toronto, Ont). 2014;17(2):33-7. doi: 10.12927/ hcq.2014.23879.
  24. Menachemi N, Chukmaitov A, Brown LS, Saunders C, Brooks RG. Quality of care inaccredited and nonaccredited ambulatory
  25. surgical centers. The joint commission journal on quality and Patient Safety. 2008;34(9):546-51. doi: 10.1016/s1553-7250(08)34069-0.
  26. El‐Jardali F, Ammar W, Hemadeh R, Jamal D, Jaafar M. Improving primary healthcare through accreditation: baseline assessment of
  27. readiness and challenges in lebanese context. The International journal of health planning and management. 2013;28(4):e256-e79. doi: 10.1002/hpm.217o.
  28. Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. Int J Qual Health Care. 2008;20(3):172-83.doi: 10.1093/intqhc/mzn005.
  29. El-Jardali F, Jamal D, Dimassi H, Ammar W,Tchaghchaghian V. The impact of hospital accreditation on quality of care: perception
  30. of Lebanese nurses. Int J Qual Health Care.2008;20(5):363-71. doi: 10.1093/intqhc/mzn023.
  31. Yousefian S, Harat AT, Fathi M, Ravand M. A proposed adaptation of joint commission international accreditation standards for
  32. hospital--JCI to the health care excellence model. Advances in Environmental Biology. 2013:956-68.
  33. Bender K, Halverson PK. Quality improvement and accreditation: what might it look like? J Public Health Manag Pract. 2010;16(1):79-82. doi: 10.1097/phh.0b013e3181c2c7b8.
  34. Al-Awa B, De Wever A, Almazrooa A, Habib H, al-Noury K, el Deek BS, et al. The impact of accreditation on patient safety and quality of
  35. care indicators at King Abdulaziz University Hospital in Saudi Arabia. Research Journal of Medical Sciences. 2011;5(1):43-51.doi: 10.3923/
  36. rjmsci.2011.43.51.
  37. Pomey M-P, Lemieux-Charles L, Champagne F, Angus D, Shabah A, Contandriopoulos A-P. Does accreditation stimulate change? A study of the impact of the accreditation process on Canadian healthcare organizations. Implementation Science. 2010;5(1):31. doi: 10.1186/1748-5908-5-31.
  38. Sack C, Scherag A, Lütkes P, Günther W, Jöckel K-H, Holtmann G. Is there an association between hospital accreditation and patient satisfaction with hospital care? A survey of 37 000 patients
  39. treated by 73 hospitals. Int J Qual Health Care. 2011;23(3):278-83. doi: 10.1093/intqhc/mzr011.
  40. Yousefinezhadi T, Mosadeghrad AM, Mohammad A, Ramezani M, SARI AA. An analysis of hospital accreditation policy in Iran.
  41. Iranian journal of public health. 2017;46(10):1347.
  42. Jafari G, Khalifegari S, Danaei K, Dolatshahi PRM, Roohparvar R. Hospital accreditation standards in Iran. Tehran: Seda publishing
  43. company. 2010.
  44. Kunkel S, Rosenqvist U, Westerling R. The structure of quality systems is important to the process and outcome, an empirical study of 386 hospital departments in Sweden. BMC Health
  45. Serv Res. 2007;7(1):104. doi: 10.1186/1472-6963-7-104.
  46. Naranjo LLS, Viswanatha Kaimal P. Applying Donabedian’s theory as a framework for bariatric surgery accreditation. Bariatric Nursing and Surgical Patient Care. 2011;6(1):33-7.doi: 10.1089/
  47. bar.2011.9979.
  48. Bahadori M, Ravangard R, Alimohammadzadeh K. The accreditation of hospitals in iran. Iranian journal of public health. 2015:295-6.
  49. Mosadeghrad AM, Akbari-sari A, Yousefinezhadi T. Evaluation of hospital accreditation standards. Razi Journal of Medical Sciences. 2017;23(153):43-54.
  50. Mosadeghrad A, Shakibaei E. Hospital accreditation implementation prerequisites. Journal of Hospital. 2017;16(3):43-56.
  51. Emami Razavi H, Mohaghegh M. Hospital accreditation standards. Tehran: Seda Publication; 2008.
  52. Ministery of Health. Look at the hospital accreditation standards. Tehran: Ministry of Health & Medical Education; 2009.
  53. Development USAI. Egyptian Hospital Accreditation Program. Tehran: Standard; 2005.
  54. Ghavami Ghanbarabadi V. Correlation between Performance Indicators and Evaluating Degree of the Hospitals of Mashhad University of Medical Sciences. Health Inf Manage. 2014;11(3):352
  55. Mohebifar R, Ghanaty E, Zaree F, Tagvaee Z, Mohseny M, Amirian S, et al. Prioritizing the Quality Criteria of Hospital Services from
  56. the View of Service Providers and Recipients. Iranian Journal of Health Education and Health Promotion. 2016;4(2):101-9. doi: 10.18869/
  57. acadpub.ihepsaj.4.2.101.
  58. JCAHO [Internet]. Joint commission on accreditation of healthcare organization. c2011 Available from: www.jointcommission.org.