Poursaki Tahmineh, Shams Lida, Maher Ali, Gharibi Farid
Department of Health Management, Policy and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
Department of Health Policy and Management, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
BMC Health Serv Res. 2025 May 27;25(1):755. doi: 10.1186/s12913-025-12930-3.
Accreditation is a practical approach to enhancing hospital service quality, requiring trained and competent surveyors for successful implementation. This study aimed to evaluate the training process of hospital accreditation surveyors in Iran based on the International Society for Quality in Health Care (ISQua) requirements and propose corrective measures.
This mixed-methods study was conducted in 2023-2024. First, the operational requirements of ISQua for surveyor training were identified and translated from existing guidelines, leading to the development of an evaluation questionnaire with four domains and 20 items. A total of 144 national accreditation surveyors completed the questionnaire, and the challenges were identified based on the analysis of the completed questionnaires. Improvement strategies for the surveyor training process were then obtained through semi-structured interviews with 17 experts in the field of accreditation. The interviews were analyzed using the inductive content analysis approach and MAXQDA software.
The compliance rate of the Iranian hospital accreditation surveyor training program with ISQua's requirements was estimated at 72% (± 0.39). The compliance rates in the domains of "educational program planning," "educational program management," "educational program implementation," and "assessing surveyor competencies" were 76% (± 0.38), 73% (± 0.38), 71% (± 0.39), and 70% (± 0.39), respectively. The proposed improvement strategies by hospital accreditation experts were categorized into three main themes: "improving the surveyor selection and evaluation process," "enhancing the surveyor training process," and "revising organizational policies," along with 20 sub-themes. Among the suggested improvements were establishing a subdivision within the accreditation office to manage surveyors, creating a surveyor management committee involving accreditation experts, allocating sufficient time for initial training, organizing periodic and continuous training programs for surveyors, and outsourcing surveyor training.
The Iranian hospital accreditation surveyor training program's compliance with ISQua's requirements is relatively satisfactory from the surveyors' perspective. However, amendments are necessary in surveyor selection, training, and the current policies of the Accreditation Office at the Ministry of Health.
认证是提高医院服务质量的一种切实可行的方法，成功实施需要训练有素且胜任的评审员。本研究旨在根据国际医疗卫生质量协会（ISQua）的要求评估伊朗医院认证评审员的培训过程，并提出纠正措施。
这项混合方法研究于2023 - 2024年进行。首先，从现有指南中确定并翻译了ISQua对评审员培训的操作要求，从而开发了一份包含四个领域和20个条目的评估问卷。共有144名国家认证评审员完成了问卷，并根据对完成问卷的分析确定了挑战。然后，通过对17名认证领域专家进行半结构化访谈，获得了评审员培训过程的改进策略。使用归纳内容分析法和MAXQDA软件对访谈进行了分析。
伊朗医院认证评审员培训计划符合ISQua要求的合规率估计为72%（±0.39）。“教育计划规划”、“教育计划管理”、“教育计划实施”和“评估评审员能力”领域的合规率分别为76%（±0.38）、73%（±0.38）、71%（±0.39）和70%（±0.39）。医院认证专家提出的改进策略分为三个主要主题：“改进评审员选拔和评估过程”、“加强评审员培训过程”和“修订组织政策”，以及20个子主题。建议的改进措施包括在认证办公室内设立一个部门来管理评审员，成立一个由认证专家组成的评审员管理委员会，为初始培训分配足够的时间，为评审员组织定期和持续的培训计划，以及将评审员培训外包。
从评审员的角度来看，伊朗医院认证评审员培训计划对ISQua要求的合规性相对令人满意。然而，在评审员的选拔、培训以及卫生部认证办公室的现行政策方面有必要进行修订。
