Status of accessible quality indices in the hospitals of Shahid Beheshti

ORIGINAL ARTICLE

University of Medical Sciences according to accreditation in 2015

Sima Marzban, Ali Ramezankhani, Majid Rezai‑Rad1, Abbas Daneshkohan, Afsaneh Najafi2
Department of Public Health, School of Health, Shahid Beheshti University of Medical Sciences, 1Department of Management, Islamic Azad
University, 2Department of Quality Improvement Unit, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

ABSTRACT
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.

Key words: Health‑care indices, hospital accreditation, outcome assessment, quality measures, teaching
hospitals

Introduction The quality of care can be searched in some domains

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]
Access this article online
Quick Response Code: Website:
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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
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DOI: Cite this article as: Marzban S, Ramezankhani A, Rezai-Rad M,

10.4103/ATMPH.ATMPH_265_17 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;10:956-62.

Correspondence:
Dr. Afsaneh Najafi, Department of Quality Improvement Unit, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran,
Iran. E‑mail: najafi.afsane@yahoo.com

956
956 © 2017 Annals of Tropical Medicine and Public Health | Published by Wolters Kluwer - Medknow
 Marzban, et al.: Status of accessible quality indices in hospitals
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
Annals of Tropical Medicine and Public Health | Volume 10 | Issue 4 | July - August 2017
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
957
 Marzban, et al.: Status of accessible quality indices in hospitals
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 standards
• First positive degree  ‑  57%–79% compliance with
standards
• First degree – 48%–56% compliance with standards
958 Annals of Tropical Medicine and Public Health | Volume 10 | Issue 4 | July - August 2017
• Second degree  –  26%–47% compliance with
standards
• Third degree – 0%–25% compliance with standards
• Below 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.
Analysis
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.
 Marzban, et al.: Status of accessible quality indices in hospitals

Results hospitalization services, the satisfaction level with the

hospital services in the excellent first‑degree hospitals
The aim of this study was to investigate the statuses was lower than other hospitals. In addition, the
of the indicators of process/outcome quality in the first‑degree hospitals were with a maximum value of
hospitals of SBUMSs by the accreditation degree. On the indices. Based on the difference between the mean
Table 1, the statuses of the indices were shown by the values of discharge and personal satisfaction with the
accreditation. hospitalization and emergency wards, maximum and
minimum mean index values were in the excellent first
In general, there was no significant difference between degree and positive first‑degree hospitals, respectively.
hospitals with different accreditations and the QIs. Based on the mild difference between mean triage
Maximum and minimum mean cesarean indices durations in the 2nd, 3rd, 4th, and 5th levels, there were
were in the excellent first degree (63.07%) and higher levels of mean indices in the hospitals with
first‑degree (47.90%) hospitals, respectively. Mean pure major accreditation degrees than hospitals with lower
levels of death in excellent first degree, positive first degrees. Maximum and minimum values of mean
degree, and first‑degree hospitals were 2.53, 1.53, and unsuccessful CPR index were in the excellent first
2.06%, respectively. Maximum death level was in the degree (71.20%) and the positive first‑degree (46.27%)
excellent first level hospitals. hospitals, respectively. Based on the mild difference
between different degrees of bed fall index, minimum
Based on the difference between mean levels of surgery and maximum mean values were in the excellent first
cancelation, maximum and minimum levels of the degree (0.02%) and the first‑degree (0.11%) hospitals,
index were in the first degree (3.02%) and the positive respectively.
first‑degree (2.41%) hospitals, respectively. In addition,
the index value in the excellent first‑degree hospitals Discussion
was 2.55%. Based on the difference between mean
satisfaction levels of the patients with emergency and 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
Table 1: Distribution process of the indices in the hospitals with major accreditation degrees were with
educational hospitals by accreditation degree lower cesarean level. There has been no continuous
Index Degree P successful accreditation in reducing the index.[14] Based
Excellent Positive First on the approach, the framework of healthcare reform
first first plan has set out that the function of the hospitals to
Cesarean rate 70.36 84.04 86.73 3.8 promote natural childbirth and reduce the cesarean
Pure death rate 3.0 3.0 3.37 3.6 rate should be used as a necessary criterion in hospital
Surgery cancelation rate 3.0 3.83 0.33 3.4
accreditation. In death index, it was expected that
Patient’s satisfaction with the 68.47 6.77 6.66 3.7
hospital services (excluding the
achieving the accreditation standards led to an
emergency services) enhancement in the health outcomes and results,
Patient’s satisfaction with the 77.83 68.33 66.3 3.4 such as pure death rate, in the hospitals with major
emergency services degrees, while the result was not confirmed in the
Discharge with personal 4.83 0.34 4.83 3.3 present study. In addition, there is a reverse correlation
satisfaction from
between the accreditation score and death rate.[19,20]
the hospitalization
wards (nonemergencies) And after accreditation, there is no change in the pure
Discharge with personal 3.00 6.77 38.34 3.37 death rate.[14] It should be noticed that more complete
satisfaction from ED judgments on the hospital death rate indicator as
Mean triage length at each triage percentage of hospitalization level in the study duration
level (for all the patients referred
seriously depend on the type of profession and hospital
to the ED in 1 month)
Level 1 3.4 3.4 3.4 3
wards, patients’ acceptance composition, and the
Level 2 0.7 3.63 0.33 3.7
referral status of the hospital.[21]
Level 3 8.63 8.0 8.3 3.7
Level 4 6.37 7.76 7.37 3.7 Despite the fact that there was a high mean cancelation
Level 5 30.3 4.38 7.60 3.4 level of surgery in the treatment centers with the lowest
Unsuccessful CPR 63.33 87.36 73.33 3.8 accreditation level, it seems that there was not favorable
Patients’ bed fall rate in the 3.33 3.37 3.33 3.6 mean distribution of the index among other degrees.
hospitalization wards Despite the fact that specific criteria had been observed
CPR=Cardiopulmonary resuscitation, ED=Emergency department in the accreditation process for the surgery room, if
Annals of Tropical Medicine and Public Health | Volume 10 | Issue 4 | July - August 2017 959
 Marzban, et al.: Status of accessible quality indices in hospitals
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
960 Annals of Tropical Medicine and Public Health | Volume 10 | Issue 4 | July - August 2017
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.
Conclusion
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
 Marzban, et al.: Status of accessible quality indices in hospitals
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.
Implications
For practical and managerial implications to be used by
hospital administrators, the following suggestions are
recommended:
1. Promoting the quality measurements among
hospitals;
2. Providing/establishing an official network for
collecting and analysis of data through therapeutic
centers through the nation;
3. Designing and measuring other quality indices and
continuous reporting of the results;
4. Notifying the indices from policy‑making bodies to
all hospitals after standardizing and preparing an
identification form for them for better clarification;
5. 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;
6. Completing the accreditation process through
adding measurements and indices based on
hospital outputs besides measurements based on
the process of accreditation plans.
Annals of Tropical Medicine and Public Health | Volume 10 | Issue 4 | July - August 2017
Limitations
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.
Acknowledgment
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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