The Way of Implementing the New Accreditation Standards at Shahid Motahhari Educational Center in Marvdasht City : A Qualitative Study

Article History: Received: 18 Aug 2018 Revised: 29 Oct 2018 Accepted: 9 Dec 2018 Background: One of the ways through which the quality of the hospital services can be improved is the accreditation, and most of the countries have launched their own accreditation system as a strategy to improve services. The aim of this research was to investigate the way of implementing the accreditation programs at Shahid Motahhari educational center in Marvdasht city. Methods: The current study was qualitative with conventional content analysis which was conducted by using the semi-structured interviews with eight officials and employees of Marvdasht Shahid Motahhari Medical Education Center in 2017. Purposeful sampling was done in this study and the next stage; the snowball sampling method was used to select the desired samples. Data were gathered to reach the data saturation point, and conventional content analysis was done to analyze the research data. Results: Two main themes and nineteen sub-themes were obtained through the nine categories. Self-confidence in the team, sense of superiority and achievement, all units’ coordination, accurate and scientific coherent supervision and management, and considering the book of standards as a guiding factor are among the strengths of this research.Poor management of programs, lack of proper context while running the program, lack of proper training, lack of financial and human resources, lack of commitment and interest in implementing the program among different groups were main identified barriers of the program. Conclusion: The effective factors on the implementation of the accreditation standards in the healthcarecenters should be identified. Besides, planning effective education, continued monitoring and assessing, creating suitable contexts of financial and human resources,consolidating the strengths and using the available potentials can be effective factors in line with the implemetation of accreditation standards.


Introduction
ne of the ways through which the quality of hospital services can be improved is accreditation, and most of the countries all over the worlds have implemented their own accreditation system as a quality improvement strategy.Accreditation as an independent voluntary program which was established by "Joint Commission on Accreditation of Healthcare Organizations" (1917).In 1998 its international branch which was called "Joint Commission International" was formed to develop a set of accreditation standards.Now, this program is the most important validation tool in the world.In Iran, the accreditation system of the hospitals was implemented for concentrated structural standards at first, but later, Ministry of Health and Medical Education developed "national accreditation standards" in order to assess the hospitals with the name of "accreditation for the hospital".This accreditation system was obtained from JCI standards andwas announced in 2010 to all the universities of medical sciences.These standards have been used for validating the hospitals since 2012 (1).
To implement the accreditation program usefully, sources and suitable infrastructure are the necessities.In line with the implementation of the accreditation plan, increasing the officials' attention to financing and culture building is really necessary.Moreover, the need for training in line with the contexts, conditions and the way of implementation of the accreditation process during the educational courses by the owners of the accreditation process in the hospitals is an inevitable necessity.Due to the presence of the capable manpower in the health system of the country, directing the ability of these potential sources is a necessity in line with realizing the goals of the health system (2).
Mosaddegh rad et al. (2015) in a study entitled "Evaluation of Hospital Accreditation Standards" concluded that 15.1 % of the hospital managers were satisfied with the content of the accreditation standards of the country hospitals.The highest level of dissatisfaction was respectively related to the same weight of the metrics, and lack of transparency of metrics and the lowest level of dissatisfaction was related to the level of national laws and regulations about the accreditation standards (3).
Salehi and Peyraviin a research entitled "Challenges for implementing the accreditation process in hospitals" which was conducted by means of narrative review and extracted data from the studies and different sources concluded thatthose organizations that the accreditation process is institutionalized in their body of education, awareness, and organizational culture will be able to reach a higher level of quality in line with providing health services.They suggested to the officials to investigate all the related conditions and context to implement the accreditation program with the challenges and pay attention to these issues in the decision-making and programming procedures.(4) In a study by Sax and Marx (2013), declaring that the value of health cares has been recognized increasingly it was indicated that qualitative case study can be used to investigate its compatibility in the developing countries.These researchers also mentioned that considering the different cultures and contexts, there are no fixed methods in line with the accreditation of health care that has the same application for all the entities and practitioners in this field.They also believe that planning authorities such as national and local organizations and international development partners should consider how the implementation of health accreditation can be deployed and compatible in the local health system and broader social and political environment. This research can provide a broader view for the officials since different people at different levels and categories of service, including senior officials, middle managers and staff working at this center were interviewed.
 Marvdasht Shahid Motahhari Educational Center is one of the most important centers in Fars province that has many visitors and covers broad geographical and demographic range of this province.This center is very important and vital for this province because all the accreditation program standards should be implemented in this center and it seems that the implementation of this program will improve the quality of the services provided for a broad range of the country population.
Marvdasht Shahid Motahhari Educational Center is one of the pioneers in implementing the accreditation programs in Iran, and with the efforts of its authorities and the efforts of the Ministry of Healthcare; it has always been among the top practitioners of these programs and has been part of the pilot centers in this area.Therefore, officials and personnel of this center, can be very helpful in promoting accreditation programs and improving the way of implementing and monitoring the standards of this program because of their experience.As a result, the current study with the aim of investigating the way of implementing the standards of accreditation in this center, tried to take effective steps towards improving health services through their views.

Materials and Methods
This study is a qualitative content analysis study which was conducted at Marvdasht Shahid Motahhari Educational Center in March-October 2017.The data gathering tool was a semistructured interview.Sampling was done through purposeful sampling method and continued until data saturation.The interviews lasted for 20 to 35 minutes.Informed consent was initially obtained from the interviewees.Eight experts were chosen in the field of accreditation, and they were interviewed These interviews were recorded by the voice recorder.
The participants in this study were selected from senior, middle and operations managers.They were one man and seven women in the age range of 30 to 40 and 50 years old, and they had doctoral degrees, master's degrees, and undergraduate degrees.These participants were providing services in different positions such as hospital manager, clinical and healthcare providers, including nurses responsible in the field of accreditation of experts working in the assessment and accreditation departments.
To ensure the validity and acceptance of the data, various actions have been taken that are as follows:

The researcher's long-term connection with the research environment
This procedure was done by the researcher due to the fact that he was one of the officials and middle managers of the studied center.He was totally familiar with the environment and the interviewees and in in the field of accreditation, he has been one of the most involved and effective authorities in this regard.

Determining a suitable time and place
Enough time was considered for the interviews and given the knowledge and confidence of the contributors to the interviewer, the participants expressed their ideas and made comments about the aim of the research and also about the present problems and barriers.
Moreover, to encode and categorize the data, two experienced encoders participated in this research and the researcher consulted with the experienced professors.
After completing each interview, the recorded interviews were instantly typed word by word.In the analyzing procedure that began when the interviews started, the semantic units and initial codes were extracted using MAXQDA 12 software.
It is necessary to mention that this study tried to comply with Helsinki declaration principles.Hence, the principles of confidentiality of information, obtaining informed consent for interviewing and having the right to withdraw from the research at each stage were ethical considerations that were followed.

Results
After analyzing the gathered data through the interviews, 190 codes were extracted that after reanalyzing and solving overlaps and removing similar and repetitive codes and merging them in the date, they were recorded as two main themes, nine categories and 19 subthemes which are shown in table 1.The most important cases were mentioned as follows.

Strengths
From the viewpoint of the experts, management components such as using the book of standards as a guiding factor and coordination of the units, structural components such as the presence of a ready context in order to implement the safety plan of patient and suitable physical structures for some of the standards,the psychological components such self-esteem in the team and sense of superiority and earning a position (achievement) are considered as the strengths which will be discussed further.

Management components 1.Using the book of standards as a guiding factor
Considering the book of accreditation standards as the basic element and lack of deviation from the requirements of these standards led to the strict enforcement of these standards.
"We try to move in the direction of accreditation, for this end, the accreditation book is considered as a guiding factor for hospitals, because of that the hospital earned +1 score (between 1 to +1 scores) in two accreditation assessments which was one of the best scores in the university" (Participant No.2)

Coordination of units
Without coordination, the implementation of each program and plan will face difficulties and barriers that accreditation is no exception in this field.In the studied medical center, the units' coordination was considered as one of the strengths of the program implementation."A very good team consolidates to improve the quality, and we tried to move in the direction of accreditation.Followingaccreditation procedure in the hospital let to strong empathy" (Participant No.2)

The structural components 1.2.1. The presence of ready context for the implementation of the patient safety plan
The previous readiness plan is one of the important issues in line with implementing the accreditation programs and from the participants' point of view this readiness is effective in the implementation of this program."In the hospital, a series of special events happened, including the issue that patients' safety subject which has been started from a few years ago, was largely considered.On the other hand, the safety issue of patients was highlighted in the process of accreditation.That's why this hospital is better than the rest of the hospitals."(Participant No.2)

Suitable physical structure for the implementation of some standards
The effect of physical structure is one of the important issues in line with implementing the standards, and it was emphasized.
"There should be some changes in the physical sources, but our hospital has fewer problems because of its modern and new structure compared with other hospitals" (Participant No.2)

Challenges and barriers
In this study, management components (changing the chief executives and senior and middle managers frequently, multiplicity of scales and hospitals assessing methods and weakness in the surveillance and evaluation system), physiological components(lack of motivation and lack of cooperation of some working groups), human source components (labour shortage.,thepresence of plane-oriented labour force that are changed frequently),training components (lack of training before the forces start working, weakness in training standards and employees accreditation), financial resources components (lack of funding), and process components (large amount of Volume 2, Issue 4, December 2018; 258-67 information and lack of enough time for accreditation) are among the most important challenges from the viewpoint of the experts.These challenges will be discussed further.

Management component 2.1.2. The presence of project-oriented manpower and changing them frequently
Instability in the management system is one of the key challenges in implementing the standards.
"The heads of the hospitals will be changed frequently, and this issue makes the condition of the hospital unstable, some of the official posts such as manager and head of the hospitals are important in the process of accreditation.Posts such as environmental health expert, and health professional should not be changed frequently.This will help the hospital to progress in a designated direction" (Participant No.3)

The multiplicity of hospital evaluation scales and methods
Due to the multiplicity of the evaluation scale, the focus on accreditation standards will be reduced and bring about several challenges for them.
"An important feature that can be considered here is that the basis of all of the visits, inspections, and judgments in a hospital is the metric that is used in the accreditation process, and it is not a model that we want from the hospital in administrative transformation.In administrative transformation, we want a model, and in another situation, we will need another model.At present, the variety of judgment of hospitals measures is so high that the hospitals themselves are confused.When the number of these criteria is high, their depth will diminish, and the appearance will only change."(Participant No.2)

Weakness in the surveillance and evaluation system
To implement each program or plan, there should be a sound and applied scientific surveillance.Implementing accreditation standards due to the weakness of the surveillance system has been faced with serious problems and challenges."In the accreditation procedure one of the challenges is that the accreditation procedure is done by Ministry of Health, while, this ministry should not implement this procedure It should be done by someone else or even voluntarily.If I want to be accredited, it should not be compulsory" (Participant No.3) "One of our problems is that we are not coordinated in the monitoring procedure.For instance, a supervisor tolerates an error and mistake, and someone else does not tolerate these offenses and s/he is strict.This contradiction in monitoring does not let us reach our desired destination" (Participant No.3)

Psychological components 2.2.1. The lack of cooperation of some working groups
The sound implementation of accreditation standards is impossible without the participation and cooperation of all involved groups.This issue has been mentioned in the current study.
"For instance, doctors do not accept responsibility.One of the issues of this lack of cooperation is related to the five common diseases in the hospital that in this case the doctors were obliged to write the clinical activities.But they do not accept this responsibility to write these activities to integrate them" (Participant No.3) "When it is announced that on a specific day the accreditation procedure will be done, we can see that they are reading and they are doing the specific activities of the section, and all of these activities are compulsory.Personnel are not motivated to do the activities related to the accreditation procedure because they are not well familiar with these issues" (Participant No.6)

Lack of motivation
The motivation and motivating factors are of the driving forces in line with the correct implementation of the accreditation program and standards that have been mentioned.
"In line with removing the obstacles and barriers, there are some solutions.One of them is allocating a budget to improve the quality, and the another one is creating necessary motivation among all the personnel from every level; whether financially or psychologically and mentally" (Participant No.1) "Personnel are exactly talking about the financial issues, not motivational factors.Personnel are not motivated to do their task completely or correctly, they just want to finish it, and nothing more" (Participant No.8)

Human resources components 2.3.1. Shortage of workforce (human resources)
No executive program can be operational without sufficient and expert manpower; including the implementation of the accreditation standards that lack of manpower has been mentioned as a major challenge in this study.
"The lack of conditions, the financial and human resource contexts, realization ofthe conditions for accreditation standards and the implememtation of these standards are so important issues, so the conditions of the standards mentioned above should be realized.When we are talking about the pharmacist, it should be mentioned that there should be a clinical pharmacist, which we do not have.Sometimes, these doctors are omitted from our personnel, or in the laboratories.Those who are working in the laboratories must have the standards of implementation, but they do not have.Therefore there should be enough force and instrument which is not right now." (Participant No.3)

The presence of project-oriented manpower and changing them frequently
Manpower transformation has been considered as one of the challenges that cause waste of time and cost and also impedes the implementation of the standard.
"How can I teach these educational contents to these project-oriented nurses who have just started their projects.Even if she/he learns these contents, his or her project will be over, and another group will start another plan.This procedure will increase my workload.Besides, the clinical personnel that should do clinical activities should be trained but there is not enough time to do so in this study.As a result, this issue will exert excessive pressure on the more experienced personnel."(Participant No.8)

Training component 2.4.1. Lack of training before the forces start working
Academic education can have a very positive and constructive role in improving the implementation of accreditation standards.
"Head and manager of the hospital must have complete knowledge and information in line with the way of implementing the metrics" (Participant No.1) "Our doctors do not accept most of the standards, why?The reason is that these standards should be taught as a curriculum content in university" (Participant No.3)

Weakness in teaching standards and employees' accreditation
Proper teaching and interpretation of standards for users are also important points in line with implementing the standards that have been considered in this study.
"No one can accurately claim that the accreditation procedure is a simple and programed procedure.All of the practitioners have different ideas and comments about this procedure based on their understanding.For instance, some indicated this metric means this and someone else indicated that the same metric does not mean that."(Participant No.4)

Financial resources components 2.5.1. Lack of finance
Without financial sources, virtually no program and plan can be implemented, and this issue has been considered more than other issues in line with implementing the accreditation procedure.
"They have not yet been able to provide the conditions.For example, the financial discussion can be mentioned as an issue that it is another challenge.This issue indicates that those hospitals that have been accredited, have enough financial sources, but we have many financial problems.Now if you consider one of the mentioned standards, there should be some supporters for

Process components 2.6.1. A large amount of information
A large amount of data and information that must be learned, taught and implemented by accreditation programs practitioners in a short time, are effective on the correct implementation of the programs.
"Suddenly, among metrics, policies, and procedure, they give me many assignments and announce that after two months there will be an accreditation process in our hospital.Now you should teach these contents and implement them; it is obviously an impossible task" (Participant No.6)

Not enough time for accreditation
While there was a large amount of information, there was not enough time for learning and implementing that information, and this issue was an important challenge that was mentioned in line with implementing accreditation programs.
"It is not necessary to implement accreditation in hospitals every two years.Many assessors are needed for accreditation procedure, and ministry will bring an assessor that he or she may not be a good choice for accreditation procedure."(Participant No.2)

Structural components
The presence of the ready context due to the implementation of the patient safety plan Suitable physical structure for the implementation of some standards

Psychological components
The sense of superiority and earning a position (achievement) Self-confidence in the team

Discussion
The findings of this study were the results of investigating the state of accreditation from experienced people's point of view and those who are active in these programs.Comparing these results withother studies, indicated that accrediting and implementing the related standards after a while that passes through its implementation in Iran, has been accepted and implemented as the most important method of measuring the quality of health services in Iran.Still, there is a long way to go.Despite the strengths that different studies have designated for this issue and have indicated them through the different viewpoints, and considering that many researchers concluded in their studies that accreditation programs have a positive impact on improving the quality of health services, many studies have challenged their positive effect and investigated this issue warily.For instance, Zoleykani ( 9) in a study in the emergency departments of eight hospitals in Sari city concluded that implementing the accreditation standards in the emergency department of these hospitals do not affect the performance indicators of the emergency department and the satisfaction of patients and staff in the department.
In another research, Shah Ebrahimi (10) by means of the first and second round of 124 hospitals accreditation procedures in Tehran and by using Data Envelopment Analysis (DEA) and data mining, investigated the relationship between accreditation and hospital performance and concluded that there was no relationship between the scores and the degree of accreditation of hospitals and their performance.In other words, the total percentage of accreditation cannot be an accurate measure to rank hospitals based on the performance.
The findings of this study also emphasized the suitability of the accreditation programs if there is suitable planning and if the barriers and problems are solved.The findings also indicated that in the case of coherent programs and using the strengths, good results can be achieved.However, the findings showed the challenges of the accreditation that makes its implementation difficult.
Analyzing the results of this study indicated that different components have a negative effect on the implementation of the accreditation standards and face it with a challenge.Management, physiological, human resources, educational, financial and process components were the desired components.
Weakness in the surveillance system was one of the mentioned barriers.With regard to the surveillance system weakness, both measuring tools and instruments and the way of doing assessment are criticized.Taslimi and Zayandeh (7) in their research point out the distortions in the evaluations and indicated that there have been some distortions in the way of creating the hospital performance evaluation systems.In the case of distortions in the way of creating performance evaluation systems, it should be noted that in hospitals, assessment and measurements process are used to judge their performance and not to enhance their performance.This inspection approach is not close to real promotion which is carried out through continuous efforts by process owners and the widespread change in hospitals.Inspection approach searches for promotion task outside the hospitals.
The multiplicity of assessing measures has been designated as one the challenges of implementing accreditation process standards and has decreased the focus on accreditation and its goals.Based on the results of this study, instead of having several measures for assessing and judging the health care centers, the focus should be on accreditation and its standards which can improve the performance.
In the field of management, this study found out that changing the head of the hospitals, senior, middle and operation managers frequently are the barriers to proper implementation of the accreditation programs and this issue also leads to an increase in costs, reduces the impact of training and prolongs the implementation of accreditation standards.
In the field of psychology, several factors have been introduced and describes as the challenges of accreditation programs implementation.Of these, the motivation and its impact have been investigated and low motivation or lack of motivation in the staff, have been considered as a factor which slows down the rate of the accreditation programs progress.Salehi and Peyravi (4) also identified the lack of motivation as a validation challenge in their research.Mosaddegh Rad and Shakbai (8) in their research considered motivation as a factor to implement accreditation and considered the motivational factors necessary for managers and employees.
Among psychological components, lack of cooperation of some working groups was considered that mostly emphasized the features of lack commitment.
In this regard, Mosaddegh Rad and Shakibaei (8) mentioned doctors' lack of cooperation and pointed to financial leverage as way to increase their participation.
This study also emphasis on the effect of human resource as an important factor in line with implementing the accreditation programs and introduce the lack of human resources and the frequent change of forces as the factors which prevent the correct implementation of accreditation programs and standards.
In this study, the lack of human resources has been considered as one of the challenges of the implementation of accreditation programs.Yar Mohammdaian et al. indicated that due to the lack of experienced and expert practitioners in the field of accreditation, this issue leads to an increased workload and, consequently, increases stress among employees, and causes dissatisfaction (5).
Salehi and Peyravi in their study also mentioned the lack of human source as a challenge in line with implementing accreditation programs.
From the viewpoints of participants in the study, educational components are among factors that are effective on accreditation implementation.Mosaddegh Rad and Shakibai also emphasized the inefficiency and inadequacy of training (8).
Yar Mohammdaian et al. have emphasized the role of education and have pointed out to the expensive and time-consuming nature of education in line with accreditation (5).
Lack of financial sources was another factor that participants considered it as a substantial challenge.Mosaddegh Rad and Shakibai have also emphasized that if there are not any resources, there is no possibility of reform.Consequently, accreditation, will not achieve the desired quality improvement.

Conclusion
Based on the views of the participants of this study, the way of implementing anaccreditation process has flaws and defects that they have been mentioned as process components and can be defined as the challenges of the accreditation process.
The results of this study showed that in the process of accreditation, the large amount of information, frequent changes, time-consuming nature of this workload and the lack of human source are considered as the substantial accreditation challenges that lead to an increase in personnel's and employees' workload.Moreover, it was identified that transitional attention to the accreditation and implementing accreditation programs and related standards in a short time have led to the incomplete implementation of the program.
Totally, this research showed that creating a suitable context and the required facilities before the implementation and also effective training of the working groups that are engaged in the programlead to its effectiveness and efficiency promotion.Therefore, solving various human, financial, process, structural and educational challenges that slow down the achievement of the objectives of the implementation of accreditation programs must be considered by the planners and implementers.

( 6 )
Although many studies have been done about accreditation, with regard to what was said, these researches can be important due to the following reasons:  Due to this fact that Marvdasht Shahid Motahhari Educational Center has been one of the pioneers in implementing accreditation program, using the experiences of officials and practitioners of this program can solve the problems and guide managers at the macro level of the country to O Downloaded from journals.ssu.ac.ir at 19:31 IRDT on Tuesday May 21st 2019 [ DOI: 10.18502/jebhpme.v2i4.277] Volume 2, Issue 4, December 2018; 258-67 implement accreditation programs and related standards.
Downloaded from journals.ssu.ac.ir at 19:31 IRDT on Tuesday May 21st 2019 [ DOI: 10.18502/jebhpme.v2i4.277] Downloaded from journals.ssu.ac.ir at 19:31 IRDT on Tuesday May 21st 2019 [ DOI: 10.18502/jebhpme.v2i4.277] surveillance and evaluation system The multiplicity of hospital evaluation scales and methods Changing the chief executives and senior and middle managers frequently Psychological components Lack of motivation The lack of cooperation of some working groups Human resources components Shortage of working force (human resources) The presence of plan-oriented manpower and changing them frequently Training component Lack of training the manpower before the work begins Weakness in teaching standards and employees accreditation Financial resources components Lack of financing Process components A large amount of information Not enough time for accreditation Downloaded from journals.ssu.ac.ir at 19:31 IRDT on Tuesday May 21st 2019 [ DOI: 10.18502/jebhpme.v2i4.277] Downloaded from journals.ssu.ac.ir at 19:31 IRDT on Tuesday May 21st 2019 [ DOI: 10.18502/jebhpme.v2i4.277]

Table 1 .
Strengths, barriers, and challenges in the implementation of accreditation standards in Marvdasht Shahid Motahhari Educational Center