Mosadeghrad and Ghazanfari BMC Health Services (2021) 21:879RESEARCHOpen AccessDeveloping a hospital accreditation model:a Delphi studyAli Mohammad Mosadeghradand Fatemeh Ghazanfari*AbstractBackground: Hospital accreditation (HA) is an external evaluation of a hospital’s structures, processes and results byan independent professional accreditation body using pre-established optimum standards. The Iranian hospitalaccreditation system faces several challenges. The overall aim of this study was to develop a model for Iran nationalhospital accreditation program.Methods: This research uses the modified Delphi technique to develop and verify a model of hospitalaccreditation. The first draft of the HA model was introduced through a critical review of 20 pioneer accreditationmodels and semi-structured interviews with 151 key informants from Public, private, semi-public, charity andmilitary hospitals in Iran. Three rounds of Delphi were conducted with 28 experts of hospital accreditation to verifythe proposed model. Panel members were selected from authors of research articles and key speakers in the areaof hospital accreditation, senior managers of the country’s health system, university professors in the fields of healthpolicy and management across the country.Results: A comprehensive model for hospital accreditation was introduced and verified in this study. The HAmodel has ten constructs of which seven are enablers (“Management and leadership”, “Planning”, “Education andResearch”, “employee management”, “patient management”, “resource management”, and “process management”)and three are the results (“employee results”, “patient and society results” and “hospital results”). These constructswere further broken into 43 sub-constructs. The enablers and results scored 65 and 35% of the model’s totalscores respectively. Then, about 150 accreditation standards were written and verified.Conclusions: A comprehensive hospital accreditation model was developed and verified. Proper attention tostructures, processes and outcomes and systemic thinking during the development of the model is one of theadvantages of the hospital accreditation model developed in this study. Hospital accreditation bodies can use thismodel to develop or revise their hospital accreditation models.Keywords: Accreditation, Delphi study, Pluralistic evaluation, Model* Correspondence: [email protected] of Health Management and Economics, School of Public Health,Tehran University of Medical Sciences, Tehran, Iran The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit Creative Commons Public Domain Dedication waiver ) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

Mosadeghrad and Ghazanfari BMC Health Services Research(2021) 21:879BackgroundOne of the main goals of a health system is to improvethe quality and safety of hospital services. Large investments in the healthcare sector, rising demand, shortageof resources, increased medical errors, and the raisingpublic expectations highlight the importance of controlling the quality and safety of hospital services providedto patients [1].Hospital accreditation is the systematic evaluation andvalidation of a hospital by an independent externalorganization using a set of structural, process, and outcome standards [2]. An accreditation certificate ensuresthe quality of hospital care and is a key measure for hospital selection by patients, patient referral by physicians,and purchase of services from hospitals by health insurance organizations, especially in competitive environments [2].Previous studies have reported different effects ofhospital accreditation programs. Some studies haveshown that these programs lead to the development oforganizational policies and procedures [3], employeetraining [4], a healthy work environment [5], cooperation among employees [6], reduced conflict and bettercommunications [7], increased responsibility [3], andhigher job satisfaction [8]. Moreover, accreditation results in the development of hospital capacity [9] and itsequipment [10], optimal use of hospital resources [10],higher quality of care [11, 12], safety [13, 14], effectiveness of hospital care [15, 16], reduction of medical errors[17–19], lower mortality rate [19], higher patient satisfaction [20], and, ultimately, better hospital performance[9–13]. In addition, receiving an accreditation certificateincreases people’s confidence in the hospital and thequality of its services [4, 21], thus increasing its reputation and popularity [10].On the other hand, some studies have questioned theusefulness of hospital accreditation programs. For example, a 2007 study on 37,000 patients in 73 hospitalsacross Germany showed that accreditation did not improve the quality of hospital care and did not increasepatient satisfaction [22]. Another study on 36 hospitalsin the US did not find a significant association betweenaccreditation and reduction in medical errors [23]. Similarly, one study on Lebanese hospitals did not find a significant association between accreditation and patientsatisfaction [17]. Some studies have shown that accreditation programs increase bureaucracy [7] and thus increase employee’s workload and resistance to theprogram [3] while increasing hospital costs [24]. The Office of Healthcare Accreditation of Iran’s Ministry ofHealth and Medical Education (MOHME) has planned anationwide hospital accreditation program with the cooperation of Iran Universities of Medical Sciences. Allthe hospitals around the country are required toPage 2 of 16participate in this government-led program and receivecertification [25]. Reimbursements to hospitals by healthinsurance organizations is based on their accreditationrating.The first round of hospital accreditation took place in2012–2013 using 8104 measurable elements for 38hospital wards and the second round took place in2013–2014 using 2157 measurable elements for 36 hospital wards [26]. The third round of hospital accreditation took place in 2016–2017 using 248 standards and903 measurable elements under 8 constructs, and thefourth round has been ongoing in 2019–2020 using 110standards and 514 measurable elements under 19 constructs [26, 27].The first and second versions of the Iranian HospitalAccreditation Model were sectional. The third andfourth versions were functional models. Although thismodel has been revised four times between 2012 and2020, there is still no logical link between its components, and not enough attention has been paid to itsstructures, processes, and outcomes. The fourth editionof the Iranian Hospital Accreditation Model includes thethree Main-constructs, i.e., “management and leadership”, “care and treatment” and “service recipient”, and19 secondary components with overlapping standards[28, 29].Accreditation has had some benefits for Iranian hospitals. Improvement in hospital facilities and equipment,employee training, development of operational plans, formulation of policies and procedures for work processes,and customer orientation have been reported as some ofthe benefits of hospital accreditation in Iran [30, 31]. A2015 study evaluated the hospital accreditation programin 547 Iranian hospitals and showed that 72% of the hospitals obtained a rating of 1 or higher in the first accreditation round [32]. However, there are studies that showthat implementation of the accreditation program has notled to improvement in hospital performance [33–35], norhas it increased employee [36, 37] and patient [38]satisfaction.The large number of standards, especially structuralstandards, vagueness of standards, overemphasis ondocumentation, impracticability of certain standards,inappropriate evaluation methods, low evaluationaccuracy, surveyors’ lack of experience and skills and/or lack of independence, inconsistent evaluation procedures, and short-term certification are some of thechallenges to the hospital accreditation program inIran [26, 32, 39, 40].The hospital accreditation model and system play akey role in achievement of the objectives of accreditationprograms. In general, hospital accreditation system consists of four components: governance, standard, method,and surveyor (Fig. 1).

Mosadeghrad and Ghazanfari BMC Health Services Research(2021) 21:879Page 3 of 16Accreditation standards must address inputs, outputs,and outcomes in a balanced manner to assist theaccreditation program in achieving its ultimate goal.Models are a great tool for showing the relationshipsamong the components of a phenomenon and sheddinglight on its complexities and blind spots. The purpose ofthe present research is to develop a model of the components of hospital accreditation standards as well as theirrelationships and the contribution of each standard tothe achievement of accreditation objectives. The resultscan provide useful insights for hospital accreditation authorities in Iran and other countries and help in developing the appropriate model for hospital accreditation.Fig. 1 component of hospital accreditationAccreditation standards must be developed based onthe principles of continuous improvement in order to enhance the quality of hospital care. Accreditation proceduremust be designed in such a way as to ensure the quality,safety and effectiveness of hospital care while leading tothe continuation of quality improvement programs inthese hospitals. Surveyors must be qualified and evaluatehospital structures, processes, and outcomes based on asystematic and reliable method. Finally, the governanceand management structure of the hospital accreditationprogram must be independent and reliable [25].Deficiencies in governance structure, procedure, and/or surveyors lead to the failure of the hospital accreditation program to achieve its intended objectives. The results of a survey of 547 hospital managers across thecountry in 2015 showed that only about 10% were satisfied with the infrastructure of implementation of thehospital accreditation program in their hospitals. Theycomplained about shortage of human, financial, andphysical resources necessary to implement accreditationstandards. Managers’ satisfaction with accreditationstandards, procedure, and surveyors was average. 15.1and 38% of the managers were satisfied with the contentof the standards and the accreditation procedurerespectively [41].Another survey of hospital manager in Zanjan Province examined the effectiveness of Iran’s hospital accreditation program in 2016 and 2018. Hospitalmanagers’ satisfaction with the accreditation systemslightly decreased in the third accreditation round compared to the second round (by 0.66%). Their satisfactionwith accreditation standard increased by 1.8%, but theirsatisfaction with accreditation procedure and implementation of standards decreased by 11.6 and 8.6% respectively. In other words, according to these hospitalmanagers, the 2016 hospital accreditation program didnot improve its performance compared to the previousrounds [42].MethodsThis research uses the modified Delphi technique to develop and verify a model of hospital accreditation inIran. The modified Delphi method was chosen becauseit allowed for expert interaction in the final round. Thisallowed members of the panel to provide further clarification on some matters and present arguments in orderto justify their viewpoints. Studies have demonstratedthat the modified Delphi method can be superior to theoriginal Delphi method and perceived as highly cooperative and effective [43]. Also, In the classical Delphi technique, Expert Panel opinions are used to design aninitial model in early stages, which is developed in laterstages and presented to the expert panel to reach consensus. However, in the modified Delphi technique, aninitial model is developed and then presented to the expert panel [44]. To develop the initial model of hospitalaccreditation, first a comparative review was conductedof the literature on accreditation models in 20 countries,including United States, Canada, Australia, Taiwan,Malaysia, New Zealand, South Korea, France, UnitedKingdom, Turkey, Denmark, Egypt, Lebanon, Saudi Arabia, Iran, India, Thailand, Indonesia, Zambia, and SouthAfrica.These are countries with a long history of hospital accreditation. Some of these models have been adapted byother countries into native accreditation models. An attempt has been made to select countries from each ofthe six WHO regions. Access to information was another criterion for country selection. A six-step protocolwas used, including identification of countries, identification of areas under study, search for relevant documents, document selection, data extraction, andreporting of the findings.First, information about the studied areas wascollected by visiting the websites of accreditation agencies in the selected countries as well as the website ofthe International Society for Quality in Health Care(ISQua). Relevant articles were also extracted from valid

Mosadeghrad and Ghazanfari BMC Health Services Research(2021) 21:879databases and reviewed. A data collection form was usedto collect data.Areas of interest included the main and subconstructs the models as well as the quantity and qualityof standards and metrics. The search of English databases covered the period from 1990 to 2020. Gale’sseven stages of framework analysis were used to analyzethe data. The results led to the identification of thecodes that were used to develop the initial model [45].Then, the strengths, weakness, and challenges of hospital accreditation standards in Iran were identifiedthrough interviews with 151 policymakers, managersand employees of MOHME’s Office of Supervision andAccreditation as well as Iran, Shahid Beheshti, Tehran,Tabriz, Isfahan, Yazd and Shiraz Universities of MedicalSciences, accreditation surveyors, managers and expertsof health insurance organizations, and hospital managersand employee. The pluralistic evaluation approach wasused and the interviewees were selected using purposiveand snowball sampling techniques. Finally, groundedtheory [46] was used to develop an initial model of hospital accreditation in Iran. Developing an initial modelusing a comprehensive literature review and presentingit to the expert panel reduces the stages of the Delphitechnique and accelerates the process of achieving thefinal results.The Delphi technique was used to verify the proposedinitial model. The members of the Delphi panel musthave in-depth knowledge of and differing perspectiveson the issue under study and be highly credible in relevant scientific communities [47]. 28 individuals agreedto participate in the present research. The inclusion criteria for the expert panel invited to take part in the studywere: Authors with at least three original research papers on hospital accreditation; keynote speakers in conferences on hospital accreditation; hospital CEOs andmanagers; and quality improvement managers as well asprofessors of health policy and management with at least3 years of experience in accreditation. The expert panelwith work experience in the field of accreditation wereselected after reviewing their CVs. Authors of this articlewere excluded from this stage. The Delphi panellists’ keydemographic characteristics are presented in (Table 1).92.8% of the participants had a PhD degree. The members of the expert panel had studied in various medicalfields as well as health policy and management andhealth economics and were employed in the MOHMEand Iran, Shahid Beheshti, Tehran, Tabriz, Isfahan, Yazdand shiraz universities of medical sciencesIn the first stage of the modified Delphi approach, theinitial hospital accreditation model was presented to theexpert panel in the form of a questionnaire. This instrument had been reviewed by five professors in the field ofhealth policy and management and its face and contentPage 4 of 16Table 1 Demographic characteristics of Delphi panel expertDemographic 30 to 40 years145041 to 50 years1346/551 years or older13/53 to 5 years828/66 to 10 years1346/411 to 15 years621/516 to 20 years13/5Master of Science27/2Doctor of Philosophy2692/8GenderAgeYears of related experienceGraduation degreeOccupationAccreditation Office Experts414/3Faculty members1450Quality Improvement managers1035/7validity had been established. The total average CVI was0.96, which is acceptable.This questionnaire provided the initial hospital accreditation model, including the main-constructs andsub-constructs of the model, the weight of the mainconstructs, and the hospital accreditation standards.Each section contained items for obtaining the opinionsof expert panel on the strengths and weaknesses of theproposed model, potential challenges to its implementations, and their recommended solutions. The opinionsof the expert panel were analysed using thematic analysis. Quotations taken from the interview transcriptswere labelled with the letter ‘E’. Finally, the proposedhospital accreditation model was modified based on theopinions of the expert panel.In the second stage, the modified model of hospital accreditation in Iran was again presented to the expertpanel in the form of a questionnaire to reach consensus.This approach is useful for converging expert panelopinions. First, a set of closed questions was used to askexpert panel about their agreement or disagreement withthe key elements of the proposed model. These questions were rated on a 10-point Likert scale from 1 for‘strongly disagree’ to 10 for ‘strongly agree’. Moreover,using an open question, experts who rated an item lessthan 7 were asked to explain their reasoning. The information obtained from the questionnaires was analysedin SPSS 24. Then, expert panel opinions were applied to

Mosadeghrad and Ghazanfari BMC Health Services Research(2021) 21:879the model. The adjusted model was presented to the expert panel in the third stage of the Delphi technique.The expert panel were asked to rate their agreement ordisagreement with the key elements of the proposedmodel on a 10-point Likert scale from 1 for ‘strongly disagree’ to 10 for ‘strongly agree’. The role of the researcherswas to study the comments of the expert panel and selectthe most repetitive suggestions for application in the initial and modified model in the second and third rounds ofDelphi. The information was analysed in SPSS 24.Measures of central tendency and dispersion, includingmean, median, and standard deviation, were used to analyse the data obtained from the second and third roundsof the Delphi method. For all questionnaire items, themean above 7 and the standard deviation less than 2, arethe acceptable values for the model to be accepted bythe expert panel.This study formed a part of a PhD thesis in TehranUniversity of Medical Sciences. Ethical approval of thestudy was obtained from the University’s Research EthicsCommittee (Ethics code: IR.TUMS.SPH.REC.1396.4870).The main ethical issues involved in this study were respondents’ rights to self-determination, anonymity andconfidentiality. Respondents were given full informationon the purpose and design of the study through a letter.Participants’ participation was voluntary and they couldstop participating in the study at any point. Written andverbal informed consent was obtained from all participants. All methods were carried out in accordance withrelevant guidelines and regulations.ResultsThe initial hospital accreditation model was developedwith 9 main constructs, including organization and management, employee management, patient management,Fig. 2 The initial proposed model of Iranian hospital accreditationPage 5 of 16resource management, process management, employeeresults, patient results, society results, and hospital results (Fig. 2), with 51 sub-constructs (Table 2) and 195standards.The proposed initial weights of the main-constructsare provided in Table 3. Initial weights indicate the impact of each of the main-constructs on the final outcomeof hospital accreditation. The proposed weights are theresult of brainstorming by the Iran’s accreditation experts in a meeting held at the headquarters of the Iran’sMinistry of Health and Medical Education. In this meeting, the experts of Iran Hospital Accreditation Program,including hospital accreditation officials, managers, university professors, surveyors, and standard setters,weighed the main-constructs.Round 1Every participant on the expert panel highlighted the necessity of developed main constructs. One universityprofessor stated that, “in general, it’s a well-designed andcomprehensive model” (E4). Another professor commented that “there are logical relationships among thecomponents of the model” (E8). According to a facultymember, “the model is designed very well. It seems to bemuch more comprehensive and structured than the previous three hospital accreditation models” (E16). Similarly, the deputy director of treatment of one of theuniversities said: “the main and sub-constructs of thismodel are thorough and comprehensive” [E26]. Theseviews were shared by another faculty member, whostated that “the relationship between the components ofthe model is logical and its special focus on outcomes isone of its strengths” (E1).However, some of the participants made suggestionsabout how to improve the primary constructs of the

Mosadeghrad and Ghazanfari BMC Health Services Research(2021) 21:879Page 6 of 16Table 2 Enablers and results of the initial proposed model of Iranian hospital accreditationEnablersResults-Organizational governance- Executive management- Hospital committees- Crisis and disaster management- Strategic planning- Hospital Operational planning- Recruitment and job analysis- Performance appraisal and career development- Observance of employees’ rights- Management of buildings and facilities- nutrition management- hygiene and prevention- equipment, supplies and materials Management- Facility management- Financial management- Health information technology management- Patient reception- Patient evaluation- Patient care- Patient identification- medicalservices- Nursing servicesproposed model. According to one university professor,“planning must be considered a separate main-construct.Planning is one of the main responsibilities of managersand separating its standards from the organization andmanagement construct would highlight its importance”(E20). In addition, some interviewees argued that employee management must be combined with resourcemanagement, but they were persuaded after being presented with the reasons for such a distinction, includingthe importance and the distinctive nature of human resources and the high concentration of standards in theresource management construct. Another recommendation was to “combine society and patient results in theproposed model” (E6).According to one of the hospital managers, the languageof certain main-constructs needed to be modified: “ITable 3 Weight of main constructsMain constructsWeight (percent)Organization and management12Staff management10Patient management12Resource management14Process management12Staff results10Patient results12Society results8Hospital results10- Continuity of care- Emergency services- Surgery and anesthesia services- Obstetrics and gynecologyservices- Dialysis services- Imaging services- Laboratory services- Blood transfusion medicineservices- Psychiatric services- Physiotherapy services- Nutrition therapy services- Pharmaceutical services- Same service- Patient medical record- The patient falls- Transfer and discharge of thepatient- Observing the rights of servicerecipients- Identify and documentprocesses- Process evaluation- Process improvement- Quality of working life- Job satisfaction ofemployees- Quality of health services- Patient satisfaction- Customer loyalty / reelection- hospital Clinicalperformance- hospital Operationalperformance- Hospital financialperformance- hospital socialresponsibilitysuggest using the phrase ‘management and leadership’instead of ‘organization and management’ and ‘management of financial resources and costs’ instead of ‘financialmanagement’” (E23). One faculty member suggested using“performance results instead of hospital results” (E4). Another faculty member said that “it is better to use the labelcustomer or client management instead of patient management to include all clients” (E6). The explanation providedby the researcher was that the standards developed in thisconstruct were related to patients and their companions.One quality manager stated that “it is better to use thephrase human capital management instead of employeemanagement” (E9). The explanation provided against thisargument was that the last words used in human resourcemanagement literature is employee management.Moreover, the participants had ideas about changingthe sub-constructs of the proposed model. One facultymember suggested that “the sub-constructs ‘quality improvement and patient safety’ and ‘infection preventionand control’ be added to the sub-construct ‘organizationand management” (E20). According to some of the participants, education should have been considered as aseparate main-construct. One hospital manager saidthat, “there should be education for all the groups thatwork in a hospital, both for employee and nonemployee, and it is necessary to have education as aseparate construct to illustrate its significance” (E15).The deputy director of treatment of one hospital arguedthat “the sub-constructs of strategic planning and operational planning are very broad and must be moredescriptive” (E26).

Mosadeghrad and Ghazanfari BMC Health Services Research(2021) 21:879One of the faculty members recommended that “thesub-construct of job analysis be removed from the subconstruct of employee management” (E27). Another faculty member recommended adding the sub-construct of“contribution management” that includes “issues of bidding, supervision, training, and suppliers” (E3). Ofcourse, some experts believed that this is not recommended as currently universities are in charge of holdingbids and hospitals practically play no important role inthis process. The director of the accreditation office of auniversity stated that “environmental health and servicerecipient support can be added to the sub-constructs”(E11). The quality manager of a hospital recommended“adding a sub-construct for the main-construct‘organization and management’ that includes decisionmaking based on evidence and collective wisdom” (E2).Another quality manager recommended “separatinghealth IT management from resource management andadding it to organization and management” (E8). According to one faculty member, “a sub-construct can beadded the resource management section to include promotion of health and hygiene in the work environment”(E1). One university professor recommended removing“nutrition management and hygiene and preventionfrom the sub-constructs of resource management” (E10).One of the participants mentioned that “it is better tocombine the main-construct ‘facilities management’ withthe sub-construct ‘buildings and facilities management’”(E24). Some of the participants believed that it was necessary to make changes in the composition of subconstructs within the main-construct of patient management. According to one faculty member, “sub-constructsof patient management must be worded more broadly.The sub-construct ‘imaging and laboratory’ can be labelled ‘paraclinical services’. The sub-construct ‘patientfalls’ can be removed. sub-constructs ‘medical care’ andFig. 3 The modified proposed model of Iranian hospital accreditationPage 7 of 16‘nursing care’ can be removed and the standards withinthese content can be listed under the sub-construct ‘general patient care’. Similarly, standards within the subconstruct ‘psychiatric services’ and ‘physiotherapy’ canbe listed under the broader sub-construct of ‘generalpatient care’” (E17).In addition, the experts on the panel were also inquired about the weight of the main- constructs. Theyevaluated the weight ratio of enablers to results to be appropriate. One of the faculty members stated that “thereis good balance between the inputs and outputs of themodel” (E7). However, some of the participants discussed their suggestions about the weight of mainconstructs. One faculty member argued that “it is betterto reduce the weight of ‘resource management’ and addto the weight of ‘employee management’” (E13). According one of the hospital managers, “the weight of the ‘patient management’ construct is too high given theweights assigned to patient and society results” (E23).The expert’s opinion was considered and the modifiedmodel including 10 constructs namely management andleadership, planning, education, employee management,resource management, patient management, processmanagement, employee results, patients and society results and hospital results (Fig. 3) and 37 sub-constructs(Table 4) were developed. The second round Delphi washeld with 28 experts.Round 2In

Accreditation has had some benefits for Iranian hospi-tals. Improvement in hospital facilities and equipment, employee training, development of operational plans, for-mulation of policies and procedures for work processes, and customer orientation have been reported as some of the benefi