Readiness of Hospitals with Quality Management Systems Based on Joint Commission on Accreditation Standards

Abstract

Introduction: Recently, the accreditation program has been used increasingly by an emphasis on patient safety. In Iran, efforts have been made to establish the accreditation program. In 2011, it replaced previous standards of traditional evaluation system. As the impact of accreditation plan need internal self assessment against minimal standards, this study aimed to survey the readiness of selected hospitals in Isfahan based on the functional model of Joint Commission on Accreditation. Methods: This cross-sectional descriptive study was conducted on four hospitals in Isfahan, Iran. Data was collected using 13 checklists based on the functional model of Joint Commission International Accreditation. The checklists were verified by the Iranian Ministry of Health. Data was collected via observations and interviews with hospital representatives in quality management. All statistical analyses were performed using SPSS. Results: The readiness of the selected hospitals in Isfahan was 64% regarding patient-based standards and 66% for facility-based standards. In general, the studied hospitals had adequate readiness for implementation of accreditation standards. Conclusion: As the study population has ISO 9000 certification, it is possible to replace old methods of process, outcome, and structure evaluation with new standards. Accordingly, patient rights have to be considered by health care employers in Isfahan. Keywords: Quality Management System; Hospitals; Accreditation; Joint Commission on Accreditation of Hospitals