Among the 19 interviewees, there were 13 (68.42%) female and 6 (31.58%) male ones, and their mean age was 53.25 ± 6.3 years. The findings of the interview analysis led to the identification of 5 main themes and 29 subthemes as described in Table 1. The main themes included macro problems and policy making, evaluators’ problems, structural and process problems, executive problems, and problems with the measures.
Accreditation macro problems and policy making incorporated 5 subthemes as follows: non-alignment of educational and medical accreditation policies, waste of resources and spending additional expenses, lack of a healthy and independent third organization, ignoring the process owners and accreditation stakeholders, and disparate and contradictory regulations and supervisions by different deputies.In this regard, the interviewees believed that educational accreditation policies were not in line with the policies of medical accreditation. One of the participants stated:
“Unfortunately, our medical and educational deputies aren’t consistent and don’t have the same policies, so, when they pay attention to education, treatment is abandoned, when they consider treatment, education is ignored”[P17].
Another participant said:
“Regarding hospital accreditation, we should do something to highlight the grading of educational accreditation in medical accreditation”[P16].
The interviewees believed that there were waste of resources and extra expenses were spent in accreditation. In this regard, one interviewee stated that:
“Accreditation doesn’t consider the fact that in some towns where there aren’t lots of patients and there’s no need to have a hospital at all, they shouldn’t build a new hospital; or in some hospitals, unnecessary sections are launched, and they buy CT scan, MRI, and so on”[P2].
The interviewees believed that currently, there was not a healthy and independent third company to carry out the accreditation process. One participant stated that:
“We need an institution or organization to act independently, develop evaluators autonomously, train independently, and even dispatch evaluators on its own”[P10].
Similarly, another participant said:
“The structure of the third organization, their type of expertise, not having stakeholders, and in fact, not having political factions, are of overriding importance. That’s why we couldn’t establish a healthy third company”[P4].
In their opinion, process owners and stakeholders were not taken notice of in accreditation. One of the participants stated that:
“We write down a lot of accreditation measures but they are infeasible and should be ignored; this shows that in the formulation of accreditation measures, the people who must be involved aren’t included, while those whose presence is somewhat unnecessary are involved, and this brings about duality”[P18].
Three of the interviewees believed that disparate and contradictory instructions and regulations were imposed on hospitals by different deputies. One participant stated that
“At times, this kind of disparate supervision misleads the hospitals; for example, each of them apply a different taste to the hospital”[P7].
Besides, a participant asserted:
“The appearance of various groups is one of our problems. There are sometimes contradictions between these measures, accreditation comments and evaluations and case evaluations”[P6].
Evaluators’ problems included seven subthemes as follows: shortage of evaluators to be assigned to different provinces, costs of travel and residence of evaluators in various provinces, evaluators’ lack of motivation due to inappropriate payments, irrelevancy of evaluators’ expertise with the areas of evaluation, involvement of a large number of people and the impact of their personal tastes on evaluations, effect of the mood and position of evaluators and evaluatees on judgment and evaluation quality, and irregular and tight schedules of evaluations. Some interviewees believed that there was a shortage of evaluators to be allocated to different provinces. A participant stated that:
“They had predicted a specific number of evaluators to register at the ministry, but there weren’t that many applicants in that field. Anyway, one of the country’s challenges is that some provinces don’t have evaluators at all”[P4].
Two of the interviewees thought that the travel and residence of the evaluators in different provinces were costly. One affirmed that:
“Now that we’re facing economic problems and should reduce expenses, their costly travel and residence is a real challenge”[P10].
However, one of the interviewees believed, inappropriate payments to evaluators would cause them to lose motivation and reduce in number. In this regard, it was said that:
“Since there is no specific motive for evaluators, it makes a big challenges and can make them lose motivation and diminish their number over time”[P10].
Three of the interviewees believed that allocation of the evaluators was irrelevant to the areas under evaluation. One participant declared:
“One specialist sees the hospital and everything else from a doctor’s point of view, while a nursing expert sees everything from the standpoint of a nurse”[P11].
Similarly, another participant stated that:
“The first and second generations were more precise, because, for example, one who evaluated the units was doing it related to his/her own expertise, but it wasn’t the same in the third generation”[P7].
Most of the interviewees believed that evaluators’ personal taste influenced their evaluations. A participant stated that:
“Hospitals toil, spend lots of energy, instruct and implement very much, then an evaluator comes and thinks everything should be done in the same way as it is in her/his own city, but that’s not right, because the nature of the measure must be considered”[P14].
As the interviewees said, evaluators’ mood and conditions were effective in judging and evaluating quality. One interviewee emphasized that:
“A tired evaluator may not evaluate well; or the evaluation by one who goes to a hospital environment where, let’s say, something bad has just happened, for example somebody has died and his/her relatives are making lots of noise, shriek and fight, will be affected by the situation”[P2].
Two of the interviewees believed that the schedules for evaluations were irregular and tight. A participant said:
Structural and process problems included the five following subthemes: ignoring the infrastructures of space, finance, equipment and human force in accreditation; unstandardized and old hospital buildings; failure to create healthy competition between hospitals; inconsistency of the strategic plan of hospitals with the accreditation program; and instrumental use of accreditation to raise hospital rank and increase tariffs. Most of the interviewees believed that the infrastructures of space, finance, equipment and human force were not taken into account in accreditation. One of the participants stated that:
“We don’t have the standards of our infrastructures, such as human force, space structure, and equipment in accreditation at all”[P16].
In addition, another participant said:
“Our nurses are exhausted, our system is worn out, we’re all disappointed, all without motivation, there are some things wrong, one of which I think is a shortage of human forces”[P15].
Four of the interviewees thought that hospital buildings were old and not standard. A participant stated:
“It’s really good to plan for having a social isolation room and a psychological isolation one in each section of the new hospitals which will be built, but it’s very hard for old hospitals which don’t even have vacant rooms”[P14].
Another participant also contended:
“Some standards aren’t applied because our hospital is old. For example, our hoteling standards aren’t perfect; so, we can’t make some departments in there”[P19].
Two of the interviewees believed that there was not healthy competition between hospitals. One of them claimed:
“Well, if you encourage competitions over numbers and indices, one of the paths that will open is data-making path, and many hospitals may be heading towards providing wrong data to universities in order to show their own statistics better than what they really are”[P1].
Some interviewees thought that the strategic plans of hospitals were not consistent with accreditation. In this regard, a participant stated:
“This very strategic plan is real when it’s done at the university; it’s real when it’s done in the ministry” [P17].
A number of the interviewees believed that accreditation was used as a tool to raise the rank of hospitals and increase the tariffs. It was said:
“A hospital is now in trouble; it doesn’t have money; we do it and ask them to consider its accreditation so high that we can increase the tariffs and allocate more money to the hospital.” [P2].
The executive problems included the following subthemes: increased workload and dissatisfaction of hospital staff, increased attention of the staff to documentation, and lack of attention to main tasks, staff resistance against accreditation due to being compulsory; physicians’ lack of involvement in accreditation due to the lack of financial gains and time-consuming nature of accreditation process. Some of the interviewees believed that increased workload was causing dissatisfaction among hospital staff. One of the participants expressed:
“We have too much expectation of our personnel though they are insufficient in number; they’re usually working double shift; we ask them for excellent accreditation; they’re also questioned regularly; these altogether have made them lose motivation. We’re all under pressure”[P15].
A majority of the interviewees believed that the issue of accreditation and the increased attention of the staff to documentation had caused the main tasks not to be properly taken into consideration. One participant stated that:
“Although accreditation was very good and they wanted it to exist, it had made the nurses away from bedside. They were going toward filing and documenting which made them further from bedside. They spent more time on writing than on dealing with the patients[P14].
Similarly, another participant maintained:
“We give each nurse 8 patients and 2 to 3 intubates; so we’ll beover-expectant to ask them do everythingstandardly, take care of the patients, have good relationships with all the patients, and provide us with excellent documentation and write down everything in detail”[P15].
Two of the interviewees believed that the compulsory accreditation program would cause the staff to resist it. A participant stated that:
“In an organization where accreditation came from a macro level, i.e. the ministry, and was considered compulsory, there would be usually resistance against it[P2].
According to most of the interviewees, doctors were not mainly involved in accreditation nor did they cooperate in its implementation. As one of the participants stated:
“Unfortunately many doctors did not get involved in accreditation perhaps because they did not receive any gains (financial gains or promotion)[P6].
A number of interviewees believed that the accreditation program was a time-consuming process. Accordingly, a participant said:
“In fact, it was a very lengthy process, and, for example, it took three complete working days and we were involved three working days in the hospital”[P4].
The problems of accreditation measures included seven subthemes as follows: interference and parallel work within the areas of responsibility of some measures, ambiguity and unclearness of some measures, using the same measures in evaluating different hospitals, weakness of the measures in some areas, the same weight of the measures; inappropriate structure in scoring the measures, and failure to review the measures in line with the changes in the social, economic and political conditions of the society. Some interviewees believed that there was interference and parallel work in the responsibility areas of some measures. In this regard, a participant pointed out that there was another issue, called parallel work. According to him:
“They sometimes had task interference which greatly caused tension in the organization: tension between human resources and nursing offices, between environmental health and infection control, or between environmental health and occupational health "[P1].
A number of the interviewees believed that some measures were ambiguous and unclear. One of the participants confirmed:
“You have to think a lot to know what the measure means. You need to read it several times although they all have recommendations and stars. When we read it to different people, they may have different impressions. It’s not so clear and explicit”[P41].
In addition, another participant stated that:
“The accreditation manual itself needed explanations. They had provided it for some measures to a great deal and supplied some explanations, but some measures were still vague and unclear [P2].
According to a majority of the interviewees, a number of similar and general measures and checklists were used to evaluate different hospitals. As one participant underlined,
“Hospitals differ from one another and they cannot be assessed with the same measures. Single specialty and general hospitals vary a lot. Even an educational hospital was different from a medical hospital [P6].
Another participant contended:
“As they use the same checklist and the same instruction to evaluate hospitals, they can’t easily distinguish between the hospitals that are inherently different, like general and private hospitals, or non-educational and educational ones”[P2].
As most of the interviewees pointed out, accreditation measures have weaknesses in some areas. One of the participants declared:
“In general, the measures of the IT syllabus definitely need to be revised. They’re outdated! The ones related to maintenance and repair, especially those related to supply, are of poor quality, too. The maintenance area has become a bit better, but it’s still far from the standards”[P1].
Furthermore, a participant stated:
“Accreditation is still financially weak and defective; that is, a hospital might have worked even well, but maybe it goes bankrupt! Lots of our public hospitals have a negative balance of course”[P2].
Some of the interviewees thought that the weight and importance of the measures ought not to be the same. A participant affirmed:
“Some measures are much more important for hospitals, i.e., they’re more important in specific types of hospitals. Therefore, this measure should be scored higher. Its score shouldn’t be the same as the one which was obtained in, for example, another hospital with a different specialty”[P6].
Additionally, a participant stated:
“If they want to change the weight of the measures, they should do it proportionate to the hospital. For example, if we have a financial measure in a private hospital, the weight of the financial measures will certainly increase much more than that of a public hospital.”[P2].
Some interviewees believed that the scoring method was unsuitable. In this regard, a participant pronounced:
“At present, the scores given to the measures are currently zero and one, and this inevitably will bring about scoring problems "[P11].
According to two interviewees, the measures needed to be revised in accordance with the changing social, economic and political conditions of the community. One of the participants stated:
“It’s necessary to review the measures every few years because social conditions, types of community diseases, and economic policies of the country are all changing over time”[P6].