The proposed hospital accreditation surveyor model is a comprehensive and integrated model that consists of a conceptual part and a procedural part. This model considers the selection, training, deployment, compensation, and evaluation. Effective management of surveyors is essential to ensure the accuracy, validity, and reliability of accreditation. In a study titled “Are accreditation surveys reliable?”, Greenfield et al. consider surveyors to be one of the key factors influencing the reliability of accreditation results (29). Surveying is a critical role that should not be taken lightly, and there should be requirements in place for the management of accreditation surveyors.
The Iranian Hospital Accreditation Program is in its infancy. Until the fourth round of hospital accreditation in 2019, there was no organized effort to manage accreditation surveyor workforce. This led to the selection of surveyors who were often not qualified to perform accreditation. Approaching surveys as an inspection and having a ‘gotcha’, poor time management, inability to establish effective communication, inability to manage conflict, inability to conduct surveys with fairness and objectivity, inability to provide effective feedback, and failure to establish coordination and team leadership are some of the challenges for surveyors in Iran’s Hospital Accreditation Program (30) (31). In addition, Iranian surveyors do not approach hospital accreditation consistently. Some surveyors are too lenient and others are too strict. Furthermore, the personality traits of the applicants are not considered in surveyor selection (32). Surveys indicate the poor performance of Iranian hospital accreditation surveyors (19).
There must be a specific structure for accreditation surveyor management. Ideally, the Hospital Accreditation Office should have a policy council as well as three committees for scientific, executive, and grievance redress matters. The policy council is responsible for management and leadership of the accreditation program. The council’s tasks include approving accreditation decisions, continuously reviewing standards and suggesting changes if necessary, approving new or revised standards, overseeing the scientific and executive committees, authorizing surveyors, and ensuring compliance with rules and regulations. The science committee is responsible for developing and updating the standards, interpreting the standards, developing a method for scoring and weighting the standards, and classifying the standards.
The executive committee manages the surveyor workforce, conducts accreditation surveys, and reports the results to the policy council. It is also responsible for the selection and training of applicants, reviewing performance appraisal results, suggesting qualified applicants to the policy council for certification, supporting survey teams in all aspects, helping surveyors in the interpretation of standards, managing daily accreditation activities, designing the survey process and providing recommendations for its improvement, reporting the results of the accreditation survey to the policy council, and determining and communicating survey costs to the policy council.
The grievance redress matters committee is tasked with overseeing the performance of the policy council, the science committee, and the executive committee, approving the recommendations of the policy council, ensuring quality control of surveys, and addressing hospitals’ complaints regarding the implementation and/or results of accreditation. In addition, the committee should periodically evaluate the accreditation program using objective criteria and indicators and take corrective action if necessary.
In the proposed model of hospital accreditation surveyors, the first step is surveyor selection. Selecting the right surveyors requires setting the appropriate criteria. In separate studies, Plebani (16) and Teymourzadeh (14) highlight the importance of having clear criteria for surveyor selection. According to Bohigas et al., surveyors around the world share in a number of features such as professional background, training, experience, and expectations (33). Selecting the best surveyors based on appropriate criteria increases the effectiveness of decisions and actions at other stages of the surveyor management process, including empowerment, deployment, and appraisal. In the absence of appropriate criteria, individuals that lack the necessary qualifications will be selected as surveyors, which will increase training costs, and if unqualified surveyors are not filtered out in later stages of the management process, the accreditation results will lose their value and reliability.
The proposed model provides a set of criteria for surveyor selection, which are classified into several categories such as general & personality, attitude, behavior, qualifications, work experience, knowledge, and skills. These criteria are assessed through written and oral tests. Surveyors must possess personality traits such as physical and mental health, reputability, self-confidence, agreeableness, modesty, trustworthiness, flexibility, and high social intelligence. These attributes allow surveyors to perform fair and objective surveys, communicate better with the hospital staff and other team members, and manage potential conflicts more effectively. Jafari Pouyan argues that survey applicants should take psychometric and personality tests (19). Similarly, ISQua considers certain personality traits such as effective communication as necessary characteristics of accreditation surveyors (23).
Having a negative attitude and focusing on deficiencies, adopting an inspection approach instead of a developmental approach and a functional view instead of a systemic view, and generalizing the attitude toward past surveys to current surveys are some of the weaknesses of hospital accreditation surveyors that have been identified in the literature (19) (18). Admission tests and interviews should be able to assess whether surveyors believe in compliance with rules and regulations, the importance and necessity of accreditation programs, continuous quality improvement, change, and the importance of protecting patient rights, so that qualified individuals with a positive attitude towards quality improvement and accreditation are selected.
In the proposed model, medicine, management, and nursing are the main specialties and laboratory science and environmental health are complementary specialties for admission of surveyors. The required work experience is determined according to the academic degree of the applicants: for undergraduates, at least 10 years of experience in senior management positions with at least 3 years of evaluation and accreditation experience; for applicants with a master’s degree, at least 5 years of experience in senior management positions with at least 2 years of evaluation and accreditation experience; and for applicants with a PhD, at least 3 years of experience in senior management positions with at least 2 years of evaluation and accreditation experience.
Bohigas et al. compared surveyor management practices in the accreditation programs of five countries. They found that surveyors across these programs have common features in their professional background, roles, and training. Two to five years of experience in the health sector, especially as a doctor, nurse, or senior manager is one of the main criteria for selection of surveyors. Surveyors are also required to have relevant qualifications (33). In countries such as the United Kingdom and Canada, a degree in a health-related disciplines is one of the criteria for selection and appraisal of surveyors. Moreover, having work and management experience in health care system is one of the basic criteria in surveyor selection (21) (22).
The behavior of surveyors is largely influenced by their personality traits, education, experience, attitude, knowledge, and skills. Surveyors must have the ability to take initiative, the desire to learn new skills, and the ability to teach; they should maintain accreditation standards, protect the integrity of the accreditation organization, build and promote a culture of continuous quality improvement, and provide effective feedback.
Knowledge and skills in matters related to the health system, familiarity with different hospital wards and units, sound understanding of the principles and concepts of survey and accreditation, ability to prioritize the subjects under survey, attention to detail, familiarity with quality improvement concepts, reporting, interviewing and computer skills, listening, speaking and writing skills, effective communication skills, teamwork skills, and the ability to adapt to difficult and complex situations are essential for accreditation surveyors.
Similarly, Jafari Pouyan argues that having knowledge of the accreditation system, concepts of quality improvement and patient safety, and survey methods will increase the accuracy of accreditation surveyors (34). Tabrizi considers insufficient knowledge and skills as a major weakness of hospital accreditation surveyors in Iran (35).
It is important for surveyors to have a comprehensive knowledge of the area they survey; otherwise, they will not have the necessary confidence to undertake a complete and accurate survey. In addition, when surveyors lack area-specific knowledge, hospitals will not take accreditation programs seriously and may be encouraged to provide an unrealistic picture of their practice. Surveyors without sufficient knowledge tend to conduct superficial assessments and focus more on documents instead of adopting a patient-centered approach.
Part of the knowledge required by surveyors comes from relevant qualifications and experience. However, surveyors also need to have general knowledge that is assessed using comprehensive admission tests. In addition, surveyors acquire further knowledge and skills through basic, advanced, and continuous surveyor training programs.
Plebani (16) and Teymourzadeh (14) have highlighted the importance of training in building the knowledge of surveyors. Jafari Pouyan(19) and Haghighi (37) and Mosadeghrad (15) consider surveyors’ lack of knowledge to be a major challenge and obstacle to the implementation of accreditation. A study of the implementation of hospital accreditation and its effects in Austrian acute-care hospitals by Milner indicated shortcomings in the areas of leadership, communication, involvement, and training of surveyors (38). Effective training can lead to the use of a consistent accreditation method by surveyors. Iranian hospital surveyors use different accreditation methods, which reduces the validity and reliability of accreditation results. This issue is highlighted in Amerion et al (39).
In most of the countries studied, including the United States (40), Canada (21), and the United Kingdom (22), the knowledge of surveyors is one of the main criteria for surveyor selection and deployment. Therefore, theoretical and practical training programs are provided to surveyors that are selected.
In the proposed model of hospital accreditation surveyors, after the initial selection, the surveyors will undergo basic training that is theoretical in nature. These training courses focus on teamwork, accreditation standards, critical, systemic and strategic thinking, time management, conflict management, interview techniques, presentation skills, group communication, self-control, reporting methods, behavioral skills, and survey skills.
ISQua also emphasizes that All surveyors should undergo a formal initial training program which include mock survey processes, legal and survey requirements, external evaluation standards and their interpretation, survey techniques, negotiating skills, performance expectations and evaluation systems, a process for dispute resolution. (41)
The progress of the participants is then assessed through interviews. Surveyors who pass this stage, which is provided through discussions, on-the-job training, and traineeship under the supervision of an experienced surveyor. In these training courses, surveyors will learn surveying techniques and how to evaluate MEs in practice. ISQua recommended that new surveyors being supported and mentored by more experienced surveyors and staff. (23)
At the end of these courses, the trainees will be evaluated in an interview and those admitted will be awarded a two-year certificate. Surveyors will receive on-the-job training on regulatory changes in the health system, new guidelines and regulations, changes in standards and MEs, and new survey methods. ISQua consider continues training to be effective of surveyors’ knowledge and skills development. (23)
In the Iranian hospital accreditation program, surveyor independence is ensured by alternating surveyors within survey teams. Surveyors are often hired under three arrangements: full-time, part-time, and voluntary. Each country selects one or a combination of the above depending on its infrastructure. Due to the fact that the accreditation program in Iran is implemented by a government agency (i.e., Ministry of Health and Medical Education) and due to insufficient budget, the use of part-time and voluntary surveyors with a daily payment and Mission payment system is more effective.
Surveyors are responsible for assessing compliance of hospitals with accreditation standards, scoring MEs through observation, interview and tracing method, providing detailed feedback to hospitals, reporting to hospitals the MEs that have relative compliance or non-compliance scores, and supporting hospitals in developing an action plan for these MEs. These are included in the employment contracts between the surveyors and the Ministry of Health as the trustee of accreditation. ISQua also emphasizes the need for contractual arrangements between surveyors and the accreditation body (23).
In the proposed model, the surveyors admitted to the hospital accreditation program are grouped according to the size of the hospital and the workload, and in each group, one individual with experience in at least 3 accreditation rounds as surveyor and with an ideal score in the surveyor evaluation program is selected as the senior surveyor.
In terms of the composition of survey teams, medicine, management, and nursing are the main specialties that are permanently present, while laboratory sciences and environmental health will be used in a consulting role if needed. The number of surveyors is proportional to the number of hospital beds.
The last stage in the accreditation surveyor model is evaluation, which is done with the aim of evaluating both the performance of surveyors and the surveyor management program. Teymourzadeh et al. argue that surveyor appraisal is one of the key requirements of surveyor management and that there should be criteria for recruitment and appraisal of surveyors. (14) Performance of surveyors is evaluated periodically based on a number of criteria such as teamwork, communication, time management, number of surveys per year, and active participation in relevant training courses, which are determined based on the feedback from surveyed hospitals, other team members, and senior surveyors as well as self-assessments. Based on the results, a decision will be made on whether to extend the individual’s survey certificate. The results will also be used to review the criteria for surveyor selection, training, and empowerment as well as the deployment and compensation mechanisms that are in place. Evaluating the performance, knowledge and skills of surveyors and the effectiveness of surveyor management programs are among the requirements of ISQua (23).