Most of the participants in this study were men (78%), with a doctorate degree and higher (67%) with 11 to 20 years of work experience.
Generally, 57 challenges to physicians' participation in accreditation activities in hospitals in eastern Iran were identified in 12 sub-concepts. (Motivation, patient demand, mutual trust and evaluation system, high workload, understanding the role of quality management unit, unrealistic accreditation, nature of accreditation, empowerment of physicians in the field of quality, effective communication, resource constraint, ambiguity in the role of uncertainty about participation) And 3 main concepts (cultural, organizational, behavioral) are categorized. The categories and concepts obtained in this research are shown in Table 2.
1. Cultural challenges
One of the challenges in this area is the lack of connection between accreditation and physician performance. In fact, between the fate and income of the physician should be connected to the type of his performance in accreditation and the legal aspects of accreditation should be seen for physicians and other medical staff.
"That we, on behalf of the governance and leadership of a medical center, have not been able to approve processes that involve physicians in accreditation. That is, the doctor knows that he is doing what he is doing, if it does not comply with the accreditation criteria the right thing will not work, or here is a headache for the doctor "And it does not achieve the desired result." (E13)
Another common obstacle is the lack of a financial incentive mechanism. Many participants cited non-use of work as an incentive and stated that this issue has greatly reduced the participation.
"If you see that the doctor is involved in the accreditation process, the percentage of his work goes up, the participation will definitely increase but when he sees it, he works so hard but gets nothing and it takes time, says why I should cooperate That's why we have to work on finances, for example, put a percentage in the work to cooperate in accreditation "To encourage more cooperation." (E22)
Differences in evaluation results with actual hospital performance are one of the barriers to physicians' cooperation in hospital accreditation.
"In the big hospitals that always and in any situation gave the first-class hospital This mentality may have arisen in physicians That is, doctors think that they can work with any condition Because there is a government hospital, with that level of income if first class "Come down, it will be very bad for both sides." (E28)
Another challenge in this area is the lack of distinction between positive practices in the field of accreditation; in fact, physicians cannot have the motivation to introduce continuous quality improvement initiatives or actively seek new opportunities in this field.
"Yeah, a lot of our staff say that we were first class now and we were fixed or we were second class and we became one, you did not give us any encouragement, what about money? We do not have financial resources, it is the same for the doctor, he says I am so "I got involved, it didn't affect me at all." (E24)
When hospitals do not reward and punish for taking the initiative in accreditation, the motivation of physicians to participate decreases.
"Another thing is that there is no feedback from this and no incentives for doctors. For example, I came to the hospital's deputy for treatment and helped in accreditation. What feedback does I get from it, financially or spiritually or in a position?" (E26)
1-2) Patient demand
One of the barriers to participating in accreditation is that unfortunately patients do not distinguish a good doctor from a bad doctor in terms of service quality.
"Sometimes you see because of the patient's company or, for example, the special circumstances that exist Sometimes some things may go away "Sometimes, due to external factors, such as the sex of the patient or the typology that accompanies the patient, it may interfere with the performance of the activity ...". (E10)
Respondents believed that patients' lack of a sense of demand played a role in their participation in accreditation.
“Definitely effective If the patient demands a lot the doctor also has to participate more And so he has to strengthen his information ... ". (E16)
1-3) Mutual trust and evaluation system
Obstacles to the accreditation process include lack of leadership and proper management of physicians, lack of managerial support for them, and inability to work with other medical professionals Also, not requiring hospital physicians by the management team to perform quality and accreditation indicators can reduce the level of participation in quality and accreditation standards
"Distrust can also play a big role, when one set works together, when they know that it benefits everyone, everyone participates together, but if they know they are bothering and the management team does not give feedback on their activities or he spends their money somewhere else as a result, it does not matter to them." (E8)
Lack of an accepted evaluation and monitoring framework for physicians for quality and accreditation indicators can lead to a decrease in the level of interest in quality and accreditation standards
"When you do effective monitoring, Not monitoring that is wrist mode, Surveillance that is arresting and helpful and educational Well, if we make monitoring like this Naturally, people tend to participate." (E5)
2. Organizational challenges
2-1) High workload
One of the biggest challenges in accreditation and quality improvement processes in a public hospital is finding the balance between quantity and quality.
"I do not think hospitals care much about quality and more quantity matters to them and because their income increases "He likes the service he offers to be more and I don't think he pursues quality much" (E15)
Concerns about the lack of time and heavy workload for physicians to perform any quality improvement activities, often cited as a major obstacle in trying to introduce a systematic approach to quality improvement in primary health care Also, sometimes general hospitals, despite admitting many patients Cause doctors not to participate enough in accreditation
"On the other hand, the problem that doctors have is that they do not have time. Finally, in teaching hospitals, faculty members are so involved in treatment education and research issues that they no longer cooperate in these areas" (E12)
2-2) Understand the role of quality management unit
There is a high degree of indifference among physicians about the need for hospital accreditation. Also, the lack of knowledge about the implementation of quality improvement activities is a major obstacle for doctors to start new quality improvement initiatives in the hospital.
"The most important part is that the doctors did not understand the harm, they do not feel the need." (E28)
"Many doctors are not involved in this process and they do not know what to do ،many doctors are not aware of the accreditation process at all " (E9)
2-3) Unrealistic accreditation
It has sometimes been observed that physicians are discouraged and interrogated by the evaluator in performing the accreditation work, which reduces their participation. Also, sometimes the lack of transparency about the collection of accreditation data and the requirements for the use of clinical data, and especially the dissemination of its findings, can discourage physicians from accreditation projects.
"One of the problems with accreditation may be that sometimes those standards or criteria or steps of accreditation are not very clear to the owners of the process and those who work in the hospital" (E1)
Increased interventions by the Ministry of Health in relation to quality improvement initiatives are often seen as a direct obstacle by physicians.
"The government hospital also tells the Ministry of Health that the flower is on its own If you give us a bad grade, "You are hurting yourself." (E23)
2-4) The nature of accreditation
Sometimes the multiplicity of methods, tools and approaches related to accreditation processes and quality improvement in practice in general leads to different types of obstacles to the active participation of physicians. Young physicians feel that these accreditation projects are more paperwork and less involved.
In some cases, the periodic and seasonal or discontinuous process of accreditation leads to the fatigue of physicians and their less participation in accreditation projects.
"It means that, unfortunately, the staff understood that quality work means making a document That is, only we are documenting " (E5)
"The accreditation itself, when it came and went, was done for two or three days and stopped, until a year later, two years later, when the accreditation was done again." (E1)
2-5) Empowering physicians in the field of quality
Many young doctors do not feel ready to take quality improvement programs, and this affects the level of participation of young physicians in quality improvement activities, On-the-job training (provided there) by physicians is considered inadequate in terms of quality improvement, which in turn reduces their participation in activities. In some cases, a gap in knowledge during study about what clinical activities related to accreditation require of physicians may cause physicians to perform less than their academic competence and potential for accreditation.
"During school You are told that your job is just to cure Well, when they tell me that I have no motivation to do quality work "And then there is no clear job description for the doctors." (E 28)
2-6) Effective communication
One of the obstacles perceived by physicians at the level of the accreditation system is the lack of a reliable information system and some complex databases that allow the comparison of criteria.
"Now we do not have a single information system, we now have about twenty models of hospital software, each with its own set of problems." (E2)
2-7) Limitation of resources
At the institutional and organizational level, lack of financial and technical resources, limited staff, lack of necessary physical infrastructure of the hospital prevents the active participation of physicians in the quality improvement initiative.
"Nurses, medical equipment and facilities, the hospital environment, the ratio of patients to doctors, all of these are effective." (E16)
3. Behavioral challenges
3-1) Ambiguity in the role
Despite efforts to improve quality in health care and in general, some GPs still have a vague view of the concept of quality improvement.
"Many doctors do not know what their role is in accreditation at all and which ones are related to them." (E12)
3-2) Uncertainty about how to participate
Physicians resist change and lack the skills to contribute to quality and accreditation activities. Many doctors also say that these quality improvement programs are new to us and very difficult to do, because we only see patients, we do it even if we are not satisfied with it.
"This is the view. We know that this accreditation that has been done this year will not change anything here in the future, so there may be an apparent effort, but there is no hope of change." (E8)
Physicians' involvement in quality improvement activities can be challenging. In fact, this culture of accreditation is less common among physicians.
"It is cultured in the nursing system, but not in the medical system, and groups should be involved, for example, it may be necessary to involve group managers and department heads in accreditation work, "When they get involved, they know more about the challenges, and they feel they need to cooperate more." (E12)