Role of a hospital accreditation program in developing a process management system

The purpose of this paper is to clarify the effects of the Iranian Hospital Accreditation Program (IHAP) on hospital processes from the viewpoint of the staff charged with establishing the program.

This qualitative study is based on the data collected in semi-structured interviews conducted in 2016, which involved eight questions. Interviews were held with 70 staff members at 14 hospitals. Managerial staff were purposively interviewed based on their familiarity and involvement with the program. The hospitals were divided into five groups, comprising public, private, charity, military and social service hospitals. A thematic analysis was carried out using the collected data.

Three themes emerged from the data, which together comprise a process management cycle: the establishment, implementation, and control phases of the program. For each phase, various positive trends, as well as hurdles for establishing the program, declared which were framed two sub-themes as positive effects and challenges.

The findings contribute to the body of evidence used by policy-makers and hospital managers to improve the change management processes related to the Iranian IHAP. Although positive changes in the process management cycles at Iranian hospitals were noted, successful implementation of the program demands a thorough assessment of the hospitals' technical and financial needs (taking into account disparities between hospitals), and there is an urgent requirement for a plan to meet these needs.