Annals of Tropical Medicine and Public Health

: 2017  |  Volume : 10  |  Issue : 4  |  Page : 956--962

Status of accessible quality indices in the hospitals of Shahid Beheshti University of Medical Sciences according to accreditation in 2015

Sima Marzban1, Ali Ramezankhani1, Majid Rezai-Rad2, Abbas Daneshkohan1, Afsaneh Najafi3,  
1 Department of Public Health, School of Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Management, Islamic Azad University, Tehran, Iran
3 Department of Quality Improvement Unit, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Correspondence Address:
Afsaneh Najafi
Department of Quality Improvement Unit, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran


Introduction: The accreditation process is conducted to enhance the organizational quality and outcomes based on the localized standards. The objective of the study was to compare quality indices in hospitals of Shahid Beheshti University of Medical Sciences (SBUMS) in Tehran with different accreditation degrees. Materials and Methods: Ten indices, representing the quality measures of inpatient cares, were selected among accredited hospitals based on importance and patient influences. In this applied descriptive study, data of 11 teaching hospitals of SBUMS were studied and analyzed by SPSS 21 using descriptive statistics and ANOVA in 2015. Data were collected from hospital records. Results: The most favorable indices - patients' satisfaction with emergency and hospitalization services, mean duration of triage (levels 2, 3, 4, and 5), and unsuccessful cardiopulmonary resuscitation (CPR) - were in the lowest ranking hospitals. Six of 10 indices, including cesarean, the death level, the discharge rate of admitted patients in the emergency department and hospital wards by personal consent, the patients' satisfaction with the hospitalization and emergency services, mean duration of triage (levels 2, 3, 4, and 5), and unsuccessful CPR were the most unfavorable in hospitals with the highest ranking, i.e., the first excellent degree. Conclusion: There was no significant difference in the indices of hospital care processes with different accreditation degrees. There were also reverse correlations between the direction of outcome changes and the accreditation level in some domains, which might require reassessment of the conduction of the program.

How to cite this article:
Marzban S, Ramezankhani A, Rezai-Rad M, Daneshkohan A, Najafi A. Status of accessible quality indices in the hospitals of Shahid Beheshti University of Medical Sciences according to accreditation in 2015.Ann Trop Med Public Health 2017;10:956-962

How to cite this URL:
Marzban S, Ramezankhani A, Rezai-Rad M, Daneshkohan A, Najafi A. Status of accessible quality indices in the hospitals of Shahid Beheshti University of Medical Sciences according to accreditation in 2015. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Oct 16 ];10:956-962
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Full Text


Investigation and enhancement of the quality of health services are highly noticed.[1] Methods to provide curative services, as well as the health level as its outcome, are assessed valuable by the countries without any attention to their resources, attempting to provide the highest quality of care for their people based on their existing resources. Nevertheless, measurement, citation, and analysis of quality level are the most important challenges coping with such attempts.[2]

The quality of care can be searched in some domains as the followings: (1) Care safety, i.e., care for patient to prevent the damages from receiving cares; (2) care effectiveness, i.e., care and treatment based on true and correct knowledge with positive and patient-centered outcomes providing needs, maxims, and personal preferences of the patient; (3) on time care, i.e., providing the required care for the patient in true time reducing unnecessary expectations and the disturbing interventions; (4) care efficiency, i.e., saving work time, time, and finance of the patient and the physician; (5) care equality, i.e., high-quality cares provided for all persons, either male or female, with different cultural, educational, financial, and social levels.[3] Nevertheless, quality measurement in such dimensions requires former policies and planning to define them operationally. In addition, providing substructures to employ high-quality services leads to financial saving and enhancement in the staff morale, as well as patients' satisfaction and professional effectiveness of the care providers.[3] The quality of services can be used as a strategy tool to success in the contest situations, and it is required for the care centers to achieve higher quality while achieving the true services requires continuous attempts to enhance the quality of providing the services.[4]

Since enhancement in the quality of the services is defined as the primary and final goal for the health organizations by the policy makers of the worldwide health organizations,[5] documentation, and analysis of the quality indicators (QIs) is focused as the main task of the providers with many innovations to reach the goal.[6] One of the most important tasks to provide save and high-quality services for the patients as main customers of the health organization is the implementation and the utilization of the accreditation standards based on the clinical and nonclinical services.[7] Accreditation is the most powerful control and assessment tool in the health system to achieve the mentioned goals, which is defined by the achievement of a health-care organization to the provided standards by an external peer assessment group independent of the same organizational level.[7] Assessment is done through reviewing the political documents, the standards, the methods, and interviews with the managers and patients, and, sometimes, through direct monitoring of the methods. Accreditation provides a competition advantage in the health-care industry, empowering the society trust in the quality and safety of cares, treatments, and services. In general, accreditation enhances the risk management, helps the organization to empower the patient's safety, and provides patient-safety culture in the organization.[8]

The revised standards of the organization have been compiled to assess the health treatment organizations in 2014 based on the expansion of the program in the countries and providing different models including the standards of Joint Committee International as well as the conduction of accreditation programs in some countries such as the UK, Denmark, the Netherland, France, and Ireland.[9] The recent attempts of the Iranian Health Ministry to conduct the program from 2012, declared that there is requirements for a long term planning to provide the substructures of the assessment tool that has been used in other countries.[10] However, access to quality data and the measurement method ensures achievement to the information of the quality of the services while the information provides the qualitative analysis background as well as backgrounds for efficient decisions for any enhancement. Therefore, designing modern information charts and management of the statistical system based on the quality documentation and its analysis are the keys to the achievement of the health-care organizations to investigate effectiveness and efficiency, as well as other signs of functional achievement.

The recent information systems of the Iranian hospitals specifically focus on the bureau processes to provide services while their citation capacity is too limited to measure either technical (clinical) or nonclinical qualities. Nevertheless, since stable and dynamic flow of quality information in such systems might increase the reliability of the inputs of accreditation programs, any enhancement in the management systems of hospital information is a serious prerequisite for accreditation.[11] Nevertheless, formal statistical information and quantitative computed signs provide a background to comprehend properly the problems of the organization, as well as to design solutions for the problems. In addition, such information reflects the effectiveness and efficiency levels of the organizational departments.

The QIs, provided by the Agency for Healthcare Research and Quality, are some response to the needs for the available multidimensional quality measures, which might be used to measure the functioning of healthcare.[12] The QIs are based on the evidence, used to identify the changes in the quality of the provided cares in both inpatient and outpatient wards. Despite the fact that there are many indices, a considerable gap in the measurement is still remaining. Index development to cope with such a gap should be of the priorities. The quantitative assessment of the health care increasingly expands the quality indices.

There are many studies on the accreditation, done in countries with more experiences, aimed at the investigation of any significant correlation between quality of input dimension and health process and outcomes and accreditation, explaining the effectiveness of accreditation on the QIs. In addition, there are some studies, done in Iran, to the same goal. A study, done on the experts' viewpoints on efficiency and accreditation, shows that, through providing substructures, selecting an accreditation model properly, and considering the beneficiaries' noticing about the necessity of accreditation and its dimensions and continuous monitoring, the state health system can positively act to achieve the goals of the hospital and to enhance the quality of the services.[13] In addition, it is shown that accreditation positively affects the functioning indices to some extent.[14] There is a significantly higher level of the patients' satisfaction with the accredited health units than centers without any accreditation certification.[15] Nevertheless, there is no significant correlation between the score of accreditation and the functioning of hospitalization quality indices and safety indices of the patient.[16],[17] In addition, there is no positive and significant correlation between the accreditation degree introduced to the hospitals by JCAHO Joint Commission Accreditation Healthcare Organization) and signs such as the hospitalization duration, the hospitalization death rate, the side-effects of hospitalization in the hospitals, and the financial resources of the hospitals. Since the alignment of the evaluating and monitoring systems and the quality of the outcome services for the customers is always noticed by the management sciences researchers, enhancement of the quality of the treatment outputs of the accredited hospitals along with the utilization of the new evaluation mechanisms for the state hospitals, as well as limited studies on the issue, led to the present study, its aim was to investigate the statuses of the hospitalization treatment quality indices in the accredited educational hospitals of Shahid Beheshti University of Medical Sciences (SBUMS) by accreditation in 2015.

 Materials and Methods

Study design

In this descriptive, cross-sectional study, all educational hospitals of SBUMS in Tehran (n = 11) were studied in 2015.

Hospital ranking in Iran

Based on studied done in a comparative study to find an accreditation suitable for health-care services, a model was recommended for Iran.[18] Based on this study, other studies and experts' view in the Ministry of Health and Medical Education (MOHME), the hospital ranking in Iran was set up by the MOHME. Experts in different disciplines annually audit hospitals, rank them and give them one of the following degrees:

First excellent degree - 80% or more compliance with standardsFirst positive degree - 57%–79% compliance with standardsFirst degree – 48%–56% compliance with standardsSecond degree – 26%–47% compliance with standardsThird degree – 0%–25% compliance with standardsBelow standard - Less than 20% compliance with standards.

The “ first positive degree” was a new degree built for those hospitals, based on their percentage which had high potentials to achieve “ first excellent degree” in the near future.

Data sources

There were 6 general hospitals and 5 specialized hospitals including children, orthopedic, heart and lungs, reconstructive and plastic surgery, and gynecology and obstetrics hospitals. In addition, there were 1, 7, and 3 hospitals with first excellent, first positive, and first degrees, respectively. Therefore, there was neither second- nor third-degree hospitals.

The inpatient care quality measures were reviewed by the research team, and 10 indices which are liable to be measured with the same setting in hospitals were selected. The validity of the indices was confirmed by 10 experts of hospital management in Iran. These experts consisted of the following people: Three accreditation experts from the deputy of treatment in the MOHME of Iran, head of accreditation office of the deputy of treatment of SBUMS, senior assessor of deputy of treatment of SBUMS, three experts from accreditation office of treatment department of SBUMS.

The selected indices included the death rate, cesarean rate, cancelation of surgery, patient satisfaction rate with emergency and other inpatient departments, discharge proportion with personal consent and other inpatient departments, patient fall, mean duration of triage stages, unsuccessful cardiopulmonary resuscitation (CPR). Since there are different source of quality data in hospitals, the indices were derived from hospital clinical records, hospital information system, and quality improvement office data after required permissions by the authorities. And in case of any difference between the records of three resources mentioned, the indices were reassessed and confirmed. The accreditation degree of the hospital was derived from the accreditation certificate of the hospital.


The status of the quality indices of the selected hospitals was analyzed by EXCEL and SPSS 21 (Statistical Package for the Social Sciences)using descriptive statistics and ANOVA by accreditation degree.


The aim of this study was to investigate the statuses of the indicators of process/outcome quality in the hospitals of SBUMSs by the accreditation degree. On [Table 1], the statuses of the indices were shown by the accreditation.{Table 1}

In general, there was no significant difference between hospitals with different accreditations and the QIs. Maximum and minimum mean cesarean indices were in the excellent first degree (63.07%) and first-degree (47.90%) hospitals, respectively. Mean pure levels of death in excellent first degree, positive first degree, and first-degree hospitals were 2.53, 1.53, and 2.06%, respectively. Maximum death level was in the excellent first level hospitals.

Based on the difference between mean levels of surgery cancelation, maximum and minimum levels of the index were in the first degree (3.02%) and the positive first-degree (2.41%) hospitals, respectively. In addition, the index value in the excellent first-degree hospitals was 2.55%. Based on the difference between mean satisfaction levels of the patients with emergency and hospitalization services, the satisfaction level with the hospital services in the excellent first-degree hospitals was lower than other hospitals. In addition, the first-degree hospitals were with a maximum value of the indices. Based on the difference between the mean values of discharge and personal satisfaction with the hospitalization and emergency wards, maximum and minimum mean index values were in the excellent first degree and positive first-degree hospitals, respectively. Based on the mild difference between mean triage durations in the 2nd, 3rd, 4th, and 5th levels, there were higher levels of mean indices in the hospitals with major accreditation degrees than hospitals with lower degrees. Maximum and minimum values of mean unsuccessful CPR index were in the excellent first degree (71.20%) and the positive first-degree (46.27%) hospitals, respectively. Based on the mild difference between different degrees of bed fall index, minimum and maximum mean values were in the excellent first degree (0.02%) and the first-degree (0.11%) hospitals, respectively.


Any reduction in the cesarean rate down to the standard level being seriously noticed by the accreditation program and state health policies, it was expected that hospitals with major accreditation degrees were with lower cesarean level. There has been no continuous successful accreditation in reducing the index.[14] Based on the approach, the framework of healthcare reform plan has set out that the function of the hospitals to promote natural childbirth and reduce the cesarean rate should be used as a necessary criterion in hospital accreditation. In death index, it was expected that achieving the accreditation standards led to an enhancement in the health outcomes and results, such as pure death rate, in the hospitals with major degrees, while the result was not confirmed in the present study. In addition, there is a reverse correlation between the accreditation score and death rate.[19],[20] And after accreditation, there is no change in the pure death rate.[14] It should be noticed that more complete judgments on the hospital death rate indicator as percentage of hospitalization level in the study duration seriously depend on the type of profession and hospital wards, patients' acceptance composition, and the referral status of the hospital.[21]

Despite the fact that there was a high mean cancelation level of surgery in the treatment centers with the lowest accreditation level, it seems that there was not favorable mean distribution of the index among other degrees. Despite the fact that specific criteria had been observed in the accreditation process for the surgery room, if such criteria noticed the results of documentation and the process requirements, the hospitals with major accreditation degrees should be more successful in reducing the surgery cancelation rate showing a significant difference with other hospitals.

There was a lower satisfaction level in hospitals with major accreditation level while it was expected that there should be a higher satisfaction level in hospitals receiving a higher degree in the accreditation process. Nevertheless, any comment is related to the accreditation methods and assessment validity in the hospitals. It seemed that the any assessment of the results relating to the customer was not considered as important in the current classification of the hospitals, and the major focus was on the processes and organizational citation. It should be noticed that the assessment of the patients' satisfaction with the accreditation process of hospitals is known as the major criterion in achieving the competencies of accreditation process. In addition, the assessment of the patients' satisfaction with the hospital services should be considered as an inseparable part of hospital accreditation process.[22]

The satisfaction level of the patients hospitalized in the accredited hospitals is significantly higher than centers without any accreditation certificate,[14],[15],[23] which is a result inconsistent with the present results. There is no significant correlation between the patient's satisfaction level and receiving a degree of accreditation criteria.[24] There is no significant correlation between accreditation and the patient's satisfaction,[25] which is consistent with the present results. Discharge with personal fulfillment is one of the most important hospital quality factors. In addition, the index is one of the five prior indices determined by the Health Ministry to assess the function of emergency ward. Therefore, the issue should be noticed in accreditation.[26] There was the highest level of discharge with personal fulfillment in the excellent first-degree hospitals, which might be due to no specific program to reduce the index level in the hospitals. In the hospitals of Tehran University of Medical University, there is no significant change in the procedure level of the index after the conduction of accreditation program.

It was expected that there should be a shorter visit and treatment activity duration of mean triage length in hospitals receiving higher accreditation degrees than other hospitals. Despite the fact that many factors such as the high number of referrers and more accurate citations in the hospitals would lead to a longer triage mean length, but if time length had been focused in accreditation degree, the hospitals, no doubt, more accurately cited and planned to reduce the index length.

If the hospital triage system follows the accreditation program, there is an enhancement in the conduction procedure based on the standards.[27]

In unsuccessful CPR index, the compilation of CPR procedure management chart and revival code call up are specifically noticed by the CPR training course based on the personal development planning, which is a necessary and general course of hospital accreditation, as well as by the state standards of hospital accreditation. However, there was no effective program to reduce the mean index in hospitals with high accreditation degree than other hospitals. The accreditation program positively affects the successful CPR index.[28] There are increases in the patients' safety indices and the quality of hospital services after accreditation.[29] There was a lower rate of bed fall in hospitals with higher accreditation degree than other hospitals. Nevertheless, it should be noticed that higher levels of the index in hospitals with lower degrees might be due to their true citation. Since the bed fall index is one of the 15 state safety indices,[30] the safety-friendly pilot hospitals should be work harder to cite the indices of patient safety, noticing that the program is done under the WHO supervision. To investigate the quality enhancement methods in medical faults including accreditation, it is shown that the progress to conduct the patient's safety standards and the medical fault management system in JCAHO accredited hospitals is considerably better than nonaccredited hospitals.[31] In addition, accreditation positively affects the patient's safety indices.[28]

The accreditation is an effective step to reach the goals of quality enhancement programs. Nevertheless, it requires policies and operational substructures, which need careful and continuous planning. In addition, the assessment of the accreditation process and its results, specially the quality of services, should be notices.


Despite the concerted attempts of hospitals to receive credits, there was no significant difference in the quality outcomes of hospitals with different accreditation degrees. In other words, there is no expected difference in the short- and long-term outcomes related to the results of hospital functioning with different accreditation degrees, and there is a reverse outcome history in some indices. Since in the present study, the citation process and measurement of such indices are included in the accreditation standards, it is expected that there are more positive outcomes in hospitals with better documentation frameworks. In addition, it seems that hospital administrators spend their time and energy to cite documents which lead to higher credits while they ignore the patient reported outcomes, which are the most important outcomes of a health-care organization, to some extent.

If the outcomes related to patients, such as health level after the discharge and the rate of the side effects or death, had been fundamentally noticed alongside the organizational and formal documents of the processes, and the patient-centered measurement, record, and follow-up methods of quality outcomes and their analysis had been considered as effective factors on the hospital accreditation degree based on the standards, such issues were surely be noticed by the hospitals.

It should be noticed that the hospitals have fully attempted to cite the processes noticing the hospital departments and accreditation. The measurement of many quality indices, such as on-time diagnosis, standard diagnosis procedure, medication or clinical treatment adapted by the evidences, the rate of the side effects of diagnosis-treatment methods, especially surgery, and health status, and the patient's quality of life, should be noticed. The results of the present study might be a starting point for more expanded studies in the future, using more effective methods in data collecting and analyzing.


For practical and managerial implications to be used by hospital administrators, the following suggestions are recommended:

Promoting the quality measurements among hospitals;Providing/establishing an official network for collecting and analysis of data through therapeutic centers through the nation;Designing and measuring other quality indices and continuous reporting of the results;Notifying the indices from policy-making bodies to all hospitals after standardizing and preparing an identification form for them for better clarification;Systemic and administrative encouragement for hospitals which have given more efforts for documentation and measuring indices, such as more allocation of funds and organizational support;Completing the accreditation process through adding measurements and indices based on hospital outputs besides measurements based on the process of accreditation plans.


This study had its own limitations: limited access to valid quantity of quality indices, and heterogeneous methods of data collection among official data in different hospitals. Although all the hospitals under study had the same compliance with the managerial system of SBUMS, other limitations such as managerial, structural, and organizational factors of the hospitals under study were not considered. In this study, only three degrees ( first excellent, first positive, and first) among 6 degrees got their degree from the evaluation, i.e. none of the hospitals of SBUMS did not have second, and third degree. Due to special bureaucratic structures, some hospitals did not cooperate in providing statistics; in this case, we need to correspond with the university administrators to find solutions to decrease the problems encountered when researchers visited the university. Another limitation was the lack of adequate information about many of quality indices and the confidentiality of providing those information related to those indices that had an effect on accreditation.


The authors would like to thank all the following experts who participated in this study: accreditation experts from the treatment Department of MOHME, head of Accreditation Department of SBUMS, Senior Assessor of Treatment Department of SBUMS, experts from accreditation department of SBUMS, head of Statistics Department of Imam Hossein Hospital (affiliated with SBUMS), and the head of Accreditation Department of Taleghani Hospital (affiliated with SBUMS).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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