1. Background
Health care services’ safety and their optimal management, as an important part of health, has attracted particular attention in recent years (1, 2). In 1990s, despite the emergence of modern medicine's ability to treat diseases, the fact was found that in some cases hospitals were not safe to implement the treatment process and caused damages to the patient (3). This made officials of the health system and area policy makers design standards and instructions in this field in order to increase the quality of service provided and enhance patients’ safety (4, 5). So far, different methods were used to improve the quality of health care centers, total quality management (TQM) being one of them (6). Total quality management is a process based on which management with partnership of employees, customers, and creditors plans for continuous quality improvement (7). Furthermore, European Foundation Quality Management is another method that is used by 60% of European countries on health care services, which includes concepts and values such as the result orientation, customer orientation, leadership, and stability of purposes (8, 9). The third method widely used is clinical governance. Clinical governance is a systematic and integrated approach to ensure accountability of services to provide high-quality health care (10).
Today, the safety of health care services has become a comprehensive knowledge and skill that has the ability to make fundamental changes in the treatment system and its evolution. In Iran, clinical governance and accreditation are two models that were designed by experts that accordingly, the issue of safety and patient orientation is particularly considered along with improve the quality of service. Both models emphasize the organization’s commitment to implement the service high standards (11, 12). Accreditation is an effective mechanism to assess the performance and improve the quality and safety of health care systems. Accreditation is the process of self-assessment and external assessment of health care organizations based on certain predefined standards (5). Accreditation not only addresses the standard state, however, it also has analytical and consultative aspects. Evidence-based medicine issues, medical ethics, reduced medical errors, and maintaining the patients’ safety are also considered as part of the accreditation process. Today, governments increasingly in developing countries use accreditation as a means to guarantee the quality of care (4, 13). Joint Commission International is the basis of accreditation across the world. Although Lebanon is the first country that, in the East Mediterranean, provided and used accreditation standards, in Iran for the first time in 1997 assessment standards and criteria for public hospitals were released (14, 15). Standards for accreditation in Iran are based on the last resources used in developed and developing countries adapted to local conditions, religious, cultural, and economic criteria, and the purpose is to improve the quality, safety and strengthen accountability in the health system (16, 17).
However, the role of implementing accreditation plan is very important in improving the state of teaching hospitals, where unfortunately, it has not been addressed in any study yet. Accordingly, the present study was conducted to determine the observance level of educational accreditation standards in teaching hospitals of Mazandaran University of Medical Sciences in 2016.
2. Methods
The present descriptive and analytical study was conducted to assess the observance level of accreditation standards in teaching hospitals of Mazandaran University of Medical Sciences in 2016. The present study protocol was studied and confirmed by the Ethics Committee of Mazandaran University of Medical Sciences. First, 5 affiliated teaching hospitals of University of Medical Sciences (Imam Khomeini, Abu Ali Sina, Shahid Zare, Razi Ghaemshahr and Fatemeh Zahra) were selected for assessment among all centers affiliated to the university randomly and with the permission from the University Education and Research Department as well as research department of selected hospitals assessment was conducted by the research team.
2.1. Data Collection Method
The given check list was sent by the Ministry of Health and Medical Education to the university. The checklist included 10 areas of assessment (educational management team, monitoring and supervision, faculty members, students, facilities and resources’ management, emergency, programs and processes, committees, the patients’ rights and safety, and clinical research). Scoring each tool measures was from 0 to 2, in addition, an option has been considered for non-assessment of the item. The score of different areas included education management team with 13 measures (maximum 26 points), monitoring and supervision of education system performance with 11 measures (maximum 22 points), faculty members with 16 measures (maximum 32 points), students with 10 measures (maximum 20 points), management of facility, space, facilities, equipment and financial and human resources and educational and research resources with 26 measures (maximum 52 points), emergency with 17 measures (maximum 34 points), educational programs and processes with 18 measures (maximum 36 points), hospital committees with 4 measures (maximum 8 points), protect the rights and safety of patients with 11 measures (maximum 22 points), and clinical research with 14 measures (maximum 28 points) were the present tool cases in the study. The total score range was from 0 to 280 in the total tool. In addition, the credit score of hospitals was calculated on the basis of the measures’ weight. This tool was first given to 15 the university specialists (faculty members of nursing department, paramedical, and medical), and they were asked to express their opinion about the tool. After the selected professors' confirmation, the tool content validity was confirmed. It is worth noting, different training courses were held to solve problems and make executives familiar with the program's implementation process. In addition, the solutions were distributed in the form of a manual among the hospital's different wards and executives.
2.2. Ethical Considerations
Prior to the study, ethical approval was obtained from the Ethics Committee of the Mazandaran University of Medical Sciences, Sari, Iran. After obtaining the approval of the Health Deputy of the University, we coordinated with the hospital officials and informed them about the goals and details of the study. In addition, the data were kept confidential.
2.3. Statistical Analysis
The analysis was performed in the statistical software SPSS 17.0. Quantitative data were reported as the mean and standard deviation and qualitative data were reported as the frequency and percentage.
3. Results
According to the results obtained, the scores obtained from the measures absolutely necessary (100 items), necessary (27 items), and developmental (14 items) were respectively 597, 161, and 95, as well as total score of educational accreditation was 853. According to Table 1, the score of health care teaching centers has been stated for each area of assessment in the tool used.
Table 1.Score of Health Care Teaching Centers
| No | Assessment Area | The Number of Standards | The Measure Level | No | Score |
|---|---|---|---|---|---|
| 1 | Educational management team | 7 | Absolutely necessary | 10 | 30 |
| Necessary | 3 | 14 | |||
| Developmental | - | - | |||
| 2 | Monitoring and supervision | 6 | Absolutely necessary | 9 | 44 |
| Necessary | 1 | 5 | |||
| Developmental | 1 | 6 | |||
| 3 | Faculty members | 13 | Absolutely necessary | 6 | 40 |
| Necessary | 7 | 43 | |||
| Developmental | 3 | 19 | |||
| 4 | Students | 10 | Absolutely necessary | 10 | 62 |
| Necessary | - | - | |||
| Developmental | - | - | |||
| 5 | Facilities and resources' management | 15 | Absolutely necessary | 13 | 88 |
| Necessary | 8 | 47 | |||
| Developmental | 5 | 34 | |||
| 6 | Emergency | 12 | Absolutely necessary | 15 | 99 |
| Necessary | 1 | 7 | |||
| Developmental | 1 | 14 | |||
| 7 | Programs and processes | 11 | Absolutely necessary | 12 | 81 |
| Necessary | 3 | 20 | |||
| Developmental | 3 | 22 | |||
| 8 | Committees | 4 | Absolutely necessary | 4 | 31 |
| Necessary | - | - | |||
| Developmental | - | - | |||
| 9 | The patient’s rights and safety | 8 | Absolutely necessary | 11 | 64 |
| Necessary | - | - | |||
| Developmental | - | - | |||
| 10 | Clinical research | 9 | Absolutely necessary | 10 | 58 |
| Necessary | 4 | 25 | |||
| Developmental | - | - |
In addition, the results of validation of each of the teaching hospitals of the university at the first and second stages are as shown in Table 2. According to the results, Imam Khomeini (RA) Health Care Center had a descending process of accreditation standards. In addition, Zare Center had no significant changes. In other cases, a significant growth was observed in health care centers achieving accreditation standards.
Table 2.The Percentage of Achieving Accreditation Standards of the University Teaching Centers According to Self-Assessment of Health Care Centers
| Orientation | Fatemeh Zahra | Abu Ali | Emam Khomeini | Zare | Razi | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| a | b | g | p | a | b | g | p | a | b | g | p | a | b | g | p | a | b | g | p | |
| Education management team in teaching hospitals | 80 | 84.6 | 0.06 | 6.3 | 17 | 61.5 | 2.65 | 264.7 | 33 | 30.7 | -0.06 | -6.1 | 20 | 30.7 | 0.55 | 55 | 17 | 46 | 1.71 | 170.6 |
| Monitoring and assessing education system performance | 100 | 100 | 3 | 13.6 | 3.67 | 366.7 | 65 | 22.7 | -0.64 | -64.6 | 35 | 13.6 | -0.60 | -60 | 3 | 27.2 | 8 | 800 | ||
| Faculty members | 68 | 65.6 | -0.02 | -2.9 | 18 | 18.7 | 0.05 | 5.6 | 40 | 37.5 | -0.05 | -5 | 40 | 34.3 | -0.15 | -15 | 18 | 46.8 | 1.61 | 161.1 |
| Students | 100 | 95 | -0.05 | -5 | 50 | 45 | -0.10 | 10 | 90 | 40 | -0.55 | -55.6 | 70 | 65 | -0.07 | -7.1 | 50 | 45 | -0.10 | -10 |
| Management of facility, space, facilities, equipment and financial and human resources and educational and research resources | 52 | 73 | 0.4 | 40.4 | 17 | 42 | 1.47 | 147.1 | 56 | 44.2 | -0.21 | -21.4 | 46 | 36.5 | -0.19 | -19.6 | 17 | 55.7 | 2.29 | 229.4 |
| Emergency of para-clinic ward of teaching hospitals | 80 | 94 | 0.17 | 17.5 | 25 | 47 | 0.88 | 88 | 90 | 64.7 | -0.27 | -27.8 | 23 | 26.4 | 0.13 | 13 | 25 | 70.5 | 1.84 | 184 |
| Educational programs and processes | 55 | 52 | -0.03 | -3.6 | 24 | 19.4 | -0.20 | -20.8 | 87 | 72.2 | -0.17 | -17.2 | 68 | 88 | 0.31 | 30.9 | 24 | 50 | 1.08 | 108.3 |
| Hospital committees | 50 | 50 | 38 | 38 | 75 | 62.5 | -0.16 | -16 | 38 | 38 | 38 | 75 | 0.97 | 97.4 | ||||||
| Protect the rights and safety of patients | 75 | 72 | -0.02 | -2.7 | 38 | 36.3 | -0.05 | 5.3 | 58 | 31.8 | -0.44 | -44.8 | 33 | 36.3 | .09 | 9.1 | 38 | 50 | 0.31 | 31.6 |
| Teaching hospital as the main field of clinical research | 64 | 60 | -0.04 | -4.7 | 33 | 21.4 | -0.36 | -36.4 | 96 | 39.2 | -0.59 | -59.4 | 29 | 25 | -0.13 | -13.8 | 32 | 7 | -0.78 | 78.1 |
| Total | 72 | 75 | .042 | 4.2 | 23 | 34.2 | 0.47 | 47.8 | 67 | 45.3 | -.032 | -32.8 | 40 | 40 | 23 | 47 | 0.43 | 43.5 | ||
Abbreviations: a, stage 1; b, stage 2; g; rate of growth; p, percent of growth.
4. Discussion
According to the results of the present study, the score obtained from accreditation of the affiliated hospitals of Mazandaran University of Medical Sciences was in the desired range. Consistent with the present study, other researchers also carried out studies on accreditation of emergency ward. Hashemi et al. (18) showed the comparison of scores obtained from emergency ward during 2 periods of accreditation indicated that the ascending process in cases has failed. Karimi et al. (19) study showed that the biomedical engineering ward had the highest level of observing standards (41%) in the initial audit and the imaging ward had the lowest level (29%). In this study, 3 months after educational interventions observing standards in all para-clinic wards on average was increased 18% percent, where the highest improvement was observed in the imaging ward. Saadati et al. (20) also showed that the most important barrier of the implementation of accreditation is the lack of medical personnel awareness and training at all levels and the lack of commitment and participation of managers and faculty members. Therefore, the solution to solve this problem is the development of education at all levels of personnel and senior managers' involvement in the implementation of the program. Furthermore, in another study, it was found that the best and most effective way to organize assessment system of the country health service accreditation is to establish an organization and institution titled a National Organization of Accreditation Iran Health Service (21).
According to the present results, most of the hospitals studied showed a significant advance in most of accreditation items that demonstrates the effectiveness of educational considerations of continuous improvement in the processes, ongoing assessment, and formation of multiple sessions of expertise and problem solving. The lack of process and/or the lack of a written policy can be detrimental to the organization that includes implementing the process personally, not specified personnel tasks in implementing the process, patients’ confusion to receive services, increasing the waiting time for patients to receive services, reduced patients' satisfaction, the lack of equipment needed due to inaccurate estimates, the lack of accountability of personnel due to not specified tasks, not ready personnel and equipment when necessary, reduced efficiency of manpower and equipment, increased hospital costs due to the loss of facilities and equipment and finally reduced hospital earnings due to the lack of record or incomplete record of service provided (22-24). Therefore, according to the above, careful identification of all processes, develop peer policy, and implement the process, according to the policy, can help improve the quality of service provided to the patients significantly.
Of course the following challenges were reported and recorded: (1) the lack of manpower for education and accreditation; (2) the existence of the project power as experts of education department; (3) the lack of participation of the hospital in the assessment of educational performance of nursing/midwifery, paramedical, and rehabilitation students; (4) the lack of executive instruction in the field of access to pathology files in anatomical laboratory (pathology) for students with confidential patient’s record; (5) the lack of updated infrastructure and technology and Internet with appropriate bandwidth for distance consult (hospital/physician and vice versa); (6) the lack of digital library with online and offline access to updated needed books and papers (full text) with advanced search, save, and transfer tools in needed computer systems for faculty members and students; (7) inactive clinical pharmacist with a specific organizational position in the center; and (8) inactive nutritionist in the center to provide expertise to clinical education groups by studied hospitals’ authorities.
4.1. The Study Limitations
In this study, despite the identification of all processes, unfortunately due to financial and manpower limitations there was no possibility to provide the equipment needed for the strict implementation of processes and since the equipment absence or defect can disturb the process of implementing processes, supply and the provision of the equipment will be an undeniable necessity in the implementation and development of accreditation programs in hospitals. On the other hand, despite all the efforts done in the implementation of accreditation program and the project, several factors continue to impede their proper implementation including the insufficient knowledge level and lack of positive attitude of all personnel to this program. It’s important to note that proper implementation of accreditation programs requires the full cooperation of all care and support departments at the hospital and university level. Therefore, it is suggested to do more studies on the causes of disruption in the process of strict implementation of standards for accreditation in the country’s health centers. In addition, more detailed intervention studies can be designed and implemented in this regard.
4.2. Conclusions
According to the present results, most of studied hospitals showed a significant advance in most accreditation items at two stages of assessment. It is necessary to discover and resolve causes and defects of reduced standards in some centers during both stages of assessing accreditation in addition to trying to strengthen and improve the state of implementing accreditation standards in all health centers.
