Developing and validating a checklist for accreditation in leadership and management of hospitals in Iran

INTRODUCTION: In the Iranian Accreditation System, leadership and management standards have been almost ignored and not paid enough and necessary attention to the structural components and the infrastructures standards in management and leadership sections. Governing body, medical staff, chief executive officer (CEO), and nursing management standards are inadequate and lack accountability. These standards could lead to reform and finally provide the context for accomplishment of an appropriate accreditation program.

MATERIALS AND METHODS: This is a descriptive, comparative, and qualitative study. It was done in two phases. The first phase included literature review of the standards of the selected countries followed by comparison of the standards of the board of trustees, medical staff, CEOs, and nursing management standards to develop the primary framework for Iranian hospitals. In phase two, the primary framework was validated true three rounds of Delphi technique.

RESULTS: Surveying the accreditation system standards in selected countries included the USA, Egypt, Malaysia, and Iran. It was found that the management and leadership standards were classify as governing body, medical staff, CEOs, and nursing management standards. The result of this study provides a framework for improvement of the Iranian national accreditation program.

CONCLUSION: In regarded to the importance of the leadership and management standards in reform and change and promotion of the health services quality, efficiency, and effectiveness, the results of this study showed that the present standards of the Iranian accreditation assessment system and guidelines lack the necessary infrastructures for implementing a successful national accreditation program.