The Compliance of the Training Program for Hospital Accreditation Surveyors in Iran With the International Requirements: A Mixed-Methods Study Publisher Pubmed



T Poursaki TAHMINEH ; L Shams LIDA ; A Maher ALI ; F Gharibi FARID
Source: BMC Health Services Research Published:2025

Abstract

Background: Accreditation is a practical approach to enhancing hospital service quality, requiring trained and competent surveyors for successful implementation. This study aimed to evaluate the training process of hospital accreditation surveyors in Iran based on the International Society for Quality in Health Care (ISQua) requirements and propose corrective measures. Methods: This mixed-methods study was conducted in 2023–2024. First, the operational requirements of ISQua for surveyor training were identified and translated from existing guidelines, leading to the development of an evaluation questionnaire with four domains and 20 items. A total of 144 national accreditation surveyors completed the questionnaire, and the challenges were identified based on the analysis of the completed questionnaires. Improvement strategies for the surveyor training process were then obtained through semi-structured interviews with 17 experts in the field of accreditation. The interviews were analyzed using the inductive content analysis approach and MAXQDA software. Results: The compliance rate of the Iranian hospital accreditation surveyor training program with ISQua’s requirements was estimated at 72% (± 0.39). The compliance rates in the domains of “educational program planning,” “educational program management,” “educational program implementation,” and “assessing surveyor competencies” were 76% (± 0.38), 73% (± 0.38), 71% (± 0.39), and 70% (± 0.39), respectively. The proposed improvement strategies by hospital accreditation experts were categorized into three main themes: “improving the surveyor selection and evaluation process,” “enhancing the surveyor training process,” and “revising organizational policies,” along with 20 sub-themes. Among the suggested improvements were establishing a subdivision within the accreditation office to manage surveyors, creating a surveyor management committee involving accreditation experts, allocating sufficient time for initial training, organizing periodic and continuous training programs for surveyors, and outsourcing surveyor training. Conclusions: The Iranian hospital accreditation surveyor training program’s compliance with ISQua’s requirements is relatively satisfactory from the surveyors’ perspective. However, amendments are necessary in surveyor selection, training, and the current policies of the Accreditation Office at the Ministry of Health. © 2025 Elsevier B.V., All rights reserved.