Introduction
Accreditation programs are increasing rapidly in developing countries, especially in the Middle East. Many healthcare organizations are engaging in improving the quality of their healthcare by adopting such programs, thereby increasing their reliability and demonstrating their commitment to improving the quality of care [1]. The participation of health workers is very important for the development of these system programs such as accreditation [2]. One of the most common strategies for improving the performance and quality of healthcare systems in more than 70 countries is hospital accreditation, a process often chosen by healthcare leaders [3]. Hospital accreditation is the process of systematic evaluation and determination of hospital credit by foreign counterparts of an independent organization to check the compliance of the hospital with the desired standards of structure, process, and outcome defined in advance [3, 4]. Accreditation evaluators collect the necessary information from managers, nurses, employees, patients, and their companions through field visits, interviews, and detailed observation of facilities, equipment, facilities, work processes, and documents, and finally decide on granting the hospital a certificate of accreditation. The ultimate goal of these efforts is to ensure the quality of medical care [5]. Accreditation is considered an integral component to evaluate and improve the quality of health and safety services by reducing the incidence of medical and nursing errors [6]. Accreditation of the hospital has many advantages in organizational dimensions, recipients of health services, and employees, including encouraging the use of evidence-based methods, improving communication and interdisciplinary team building, increasing the satisfaction and work commitment of employees, protecting the rights of patients, improving the quality of services, hospital, reducing hospital infections and medical errors, and improving patient safety [3, 7]. However, the correct implementation of accreditation is always influenced by human, operational, and managerial factors that can impose limitations on the effectiveness of the quality of care [8]. Among the operational obstacles of accreditation, we can mention capital and financial obstacles, obstacles related to employees, structural obstacles, and obstacles related to patients [9]. However, the correct implementation of accreditation is always influenced by human, operational, and managerial factors that can impose limitations on the effectiveness of the quality of care [8]. Among the operational obstacles of accreditation, we can mention capital and financial obstacles, obstacles related to employees, structural obstacles, and obstacles related to patients [9]. The maternity department is one of the most important departments of hospitals, human life starts from it and the health at mother and baby is important in it [10]. Mother and baby health is one of the indicators of development and one of the main components of primary health care. The performance of the maternity department also affects the attitude of patients towards the hospital [11]. WHO reports that maternal mortality is unacceptably high. In 2020, about 287,000 women died during and after pregnancy and childbirth. Approximately 95% of all maternal deaths occur in low- and lower-middle-income countries, and most are preventable [12]. Harris et al. (2022) in their UK study emphasized that in recent years, several reports have shown the need for transformation in maternity services to improve safety and quality of care [13]. The poor implementation of maternal care programs is one of the common problems of the gynecology and obstetrics department, which leads to harming mothers [14]. These avoidable harms in maternity services can lead to serious disability and profound distress for women, their children, and their families [15]. Accreditation programs are one of the most important tools for improving the quality of care and patient safety [16]. In Iran, many studies have been conducted in maternity departments, but the accreditation process has not been studied. And this is while the accreditation process guarantees the quality of care for mother and baby [17, 18]. However, an article that deals with the issue of accreditation and its obstacles and facilitators has not been done in Iran. Considering the decrease in population growth in Iran, health managers have paid special attention to the health of mothers and babies. According to the new policies of the Iranian Ministry of Health, including the Youth Population Law, the accreditation of obstetrics and gynecology departments has been emphasized to ensure the quality of maternal and newborn services. The purpose of this research is to explain the facilitating factors and obstacles in the implementation of the accreditation process in maternity departments. When researchers have sufficient knowledge about a phenomenon, the content analysis approach is useful for improving knowledge and awareness without interferenceing a researcher’s perspective [19]. Because we do not have enough data on the barriers and facilitators of completing accreditation standards in the maternity departments, qualitative content analysis can be useful for the purposes of this research. Qualitative content analysis by extracting comprehensive data will lead to a deep understanding of the barriers and enablers of accreditation in this departments.
Methods
Design
This study aims to answer the question of the effective barriers and facilitators in completing the accreditation standards from the perspective of midwives in the delivery department. Therefore, in this research, qualitative conventional content analysis was conducted from March to April 2013 in Qom province, Iran. A conventional content analysis was used in this study, because the researchers sought to organize received data [20].
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Setting and participants
The participants were selected from the maternity departments of two referral hospitals in Qom province. The inclusion criteria were to have a bachelor’s degree or higher in midwifery and at least one year of clinical experience in maternity departments. With the guidance of the supervisor and head midwife, midwives who were members of the accreditation team and had rich experiences in completing the accreditation standards were identified. Purposive sampling was used for this research.
Data collection
Data collection was done through in-depth semi-structured interviews with the twelve midwifes. The interview guide was finalized based on the opinions of the research team members, a qualitative research expert outside the research group, and one pilot interview. Interviews were conducted in a comfortable environment where the participants did not feel restricted or uncomfortable sharing information. For bracketing and mitigate the potential effects of presuppositions in this study, For bracketing, interviews and data analysis were conducted by authors who were not midwives, had no relationship with the The interviews were conducted by the corresponding author, who is a nurse and expert in qualitative research. The first and eighth author was midwife. To control the possible impacts of preconceived assumptions and the background of the first and eighth author in classifying and analyzing participants’ views, they were not involved in the data analysis stage. After presenting the objectives of the study to the participants, the interview began with an open-ended question: " Tell us about your experience in participating in the accreditation of your ward”. Probing questions were also used to elicit. Further details or clarification during the interviews The duration of each interview was between 30 to 45 minutes. The number of participants was determined by the data saturation. Consensus in reaching saturation was obtained by several group reviews of the data by the research team and the approval of two external reviewers who were experts in qualitative research. Data saturation was achieved in the 10th interview. In the categories of the extracted codes in the ninth and tenth interviews, based on the investigations of the research team and two external reviewers, no new data was obtained to form new subcategories and categories, but to ensure that no new data was extracted, two more interviews were conducted and in these two the interview also did not extract new data [21]. Interviews were audiotaped and fully transcribed verbatim in Microsoft Office Word on the same day.
Data analysis
Data analysis was carried out using conventional content analysis according to Graneheim and Lundman, manually and simultaneously with data collection. After several readings of each interview transcript and identification of the main ideas, the words, sentences, and paragraphs that were relevant to the study aim were extracted as units of meaning. These units of meaning were then abstracted and labeled in the form of codes. Generated codes were categorized into subcategories and categories for similarities and differences. Finally, the main theme of the study was extracted as a description of the latent content of the data [10].
Rigor
The research team systematically completed the transferability, credibility, dependability, and confirmability of the extracted data to enhance trustworthiness. Transferability and credibility were established by prolonged engagement with the data, selecting a midwife, and checking data. In this study, to ensure accurate coding and in-depth analysis, it took two months to complete the interviews. Each interview was transcribed and coded immediately after completion. The extracted codes were checked by the research team and external reviewers, and then subsequent interviews were conducted. According to the advice of two external reviewers who were qualitative experts, to achieve deep insight, the influencing variables in the experience of the participants (being junior and senior, age, work experience, education level, and work position) in the accreditation process were determined to achieve diversity. Based on the guidance of two external observers during the formation of categories and sub-categories, to confirm the correctness of the extracted data, the data were checked by the majority of the research team. Data review was done by peer checkers in several group sessions with the presence of the research team. Dependability was a regular basis for all research steps. Also, for peer-checking, two researchers and academic staff outside the research team with experience in qualitative research reviewed and approved the findings. Conformability was applied through research team meetings to discuss, review, and approve the extracted codes and categories. Also, the researchers provided a clear description of the context of the study, the characteristics of participants, and the process of data analysis and also provided sufficient quotes. The authors used SRQR (Standards for Reporting Qualitative Research) to improve the transparency of all aspects of qualitative research by providing clear standards for reporting qualitative research [11, 22].
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Ethics approval and consent to participate
This research was approved by the National Committee for Ethics in Biomedical Research and the Ethics Committee of Qom University of Medical Sciences, Qom, Iran (approval code: IR.MUQ.REC.1402.060). Participants were informed about the study aim, the voluntary participation, and the right to withdraw from the study. Formal informed consent was obtained from all participants on the day of the interview. The participants were assured not to reveal their names in writing the interviews, in the quotes, coding, and reporting the results, and we showed these actions in the peer check phase.
Limitations
A limitation of our research was the lack of participation of gynecologists in expressing their experiences of the accreditation process. Expressing the experiences of gynecologists, who form a vital component of the medical team in maternity wards, will shed new light on the barriers and facilitators of the accreditation process. We support future research efforts to clarify the experiences and perspectives of gynecologists on the accreditation process, while simultaneously integrating their insights with other members of the medical team. Multidimensional experiences of gynecologists and midwives lead to a more complete and comprehensive analysis the barriers and facilitators on the accreditation process.
Results
Most of the participants were clinical midwives (8) with a bachelor’s degree (10) and work experience of 15 ± 3 years (Table 1). Three categories were extracted for accreditation barriers: Management barriers with four subcategories, Administrative barriers with three, and Personal barriers with six subcategories. Two categories were extracted for accreditation facilitators: Actual facilitators with four subcategories and Potential facilitators with four subcategories (Table 2).
Table 1
Demographic characteristics
Parameter | Frequency | |
|---|---|---|
Educational level | Bachelor’s degree Master’s degree | 10 2 |
Work Experience | 15 ± 3 |
Table 2
Subcategories and categories of accreditation barriers and facilitators
Category | Subcategory |
|---|---|
Management barriers | -The lack of cultural structure -Shortage of personnel -Not entering gynecologists into the accreditation process -Non effective management |
Administrative barriers | -Time-consuming and consuming tasks of accreditation -The dilemma between accreditation indicators and hospital standards -Imbalance between shift work activities, and participation in the process of accreditation |
Personal barriers | -Paperwork and a lot of incoming information -Head midwife’s stress and concern for accreditation -Inappropriate staff attitude toward accreditation -Reducing the motivation in the midwife -Midwife feel forced to do accreditation -Resistance to change |
Actual facilitators | -The availability of in-service training courses -Determining the errors and clarification activities with documentation -Clinical midwifes’ involvement in decisions of the accreditation -Risk reduction and job security |
Potential facilitators | -Hope for a better future with the accreditation process -Satisfaction of the accreditation, transparency -Emphasis on efficiency and effectiveness |
Accreditation barriers
Management barriers
The lack of Cultural structure
Creating an organizational and work culture to complete the accreditation standards in all human, equipment, and environmental resources should be defined by the managers of this department for all personnel of this department. The necessity of dividing the personnel to complete the standards and the participation of all the personnel of this department can be important in creating the organizational culture of the accreditation process. The need to improve organization culture and provide appropriate standards was one of the themes extracted from participants’ statements. Since departmental accreditation has been implemented in recent years and is known as a new and less known phenomenon among managers and employees of maternity departments, its cultural structure has not yet been properly formed by managers and employees as a necessity and They don’t necessarily look at it.
“We have implemented this culture in some parts of the department, for example, at our delivery part. Automatically its personnel provided. delivery part holds its own exam. This part gives its measures to staff and wants to find solutions. All persons are involved in accreditation.” (p3).
Shortage of personnel
Not allocating financial resources to provide more personnel and allocating income for the personnel of this department to complete the accreditation standards makes the lack of manpower in this part of the accreditation process more prominent. High work pressure and a large number of patients in maternity departments cause fatigue and pressure on the personnel. Completing accreditation procedures at the same time as taking care of patients in work shifts creates a heavy workload for midwives.
“Accreditation says it needs one midwife per two patients. But they say one midwife for three patients… While our evening shift and night shift, two staff for 10 beds! Then assume for the patient, God forbid, we neglect to the patient one moment. One midwife must sit behind the monitors; one must follow the gynecologist orders and visits. Maybe patient wanted to sit next to the bed to dinner, you must be careful to possible faint. This is thought in patient safety, but in personnel shortages it causes problems.” (P6).
Not entering gynecologists into the accreditation process
Many accreditation indicators require teamwork, and some of these indicators require gynecologists to cooperate and perform, which in many cases, for various reasons, gynecologists refuse to do, and the performance of this indicator is imposed on maternity unit staff.
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“We had so much trouble with Accreditation. Its more pressure is on the midwifes. While half of the Accreditation rules are for gynecologist, they don’t perform it at all. For example, informed consent forms and many of forms are for gynecologist, but they do not fill out the forms. But because they have asked us, we fill forms ourselves. We must beg the doctors to stamp. We have a lot of trouble. We do their work.” (p7).
Non-effective management
To carry out accreditation correctly and accurately, it is necessary to create internal and external motivation for the staff, given the pressure of work that accreditation places on them. From the midwives’ point of view, the management style of the managers of this department does not provide the necessary motivation to participate and carry out accreditation activities with quality.
“Exactly, we are now have endured two and a half years. And seemingly for it has not predicted a good budget for it. Well, pays has improved a little to one year before. But financial can not only satisfied persons. Leadership must know how to deal with personnel, should see what needs are. Respect, encourage, and shift work…. the leader must be able to influence in personnel. With this shortage of midwifes, we can do many things if there was motivation. " (P11).
The managers of this department decided to appoint a team with very few members to complete the accreditation standards and did not include some in this team due to low work experience or lack of skills in completing the standards.
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“In this department, a limited number of personnel are involved in accreditation and the rest of the personnel are involved in clinical care… If all personnel were involved, the standards would be completed faster and easier.” (P6).
Administrative barriers
Time and energy-consuming tasks of accreditation
It takes a lot of time and energy to complete the accreditation process properly because it is so extensive and detailed. Engaged midwives spend a great deal of time and energy to accurately and completely meet standards of accreditation and patient care.
“Us midwifes cannot go home to prepare for In-service exams. I should frequently come to assess staff. I say these challenges are really so much. It takes a long time and energy.” (P4).
The dilemma between accreditation indicators and hospital standards
Sometimes a problem arises because of a conflict between accreditation indicators and hospital standards. This leaves midwives feeling confused about how to implement validation.
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A participant says: “authorities say of ‘five RIGHT’. But to do tasks in properly, one midwife cannot do triage and CPR at the same time. First they must meet the standards and then say to do accreditation.“(P9).
Imbalance between shift work activities, and participation in the process of accreditation
Failure to allocate a certain number of work shifts for clinical care and some to participate in the completion of the standards causes great difficulties for the personnel in completing the standards. The participation and cooperation of personnel in the implementation of accreditation processes requires internalized motivations and also of monitoring systems on the correct implementation of these processes, and this happens less in the evening and night shifts.
“ Most midwifes are active in accreditation in the morning shift, but in evening and night I don’t think to have participation.“(P5).
Personal barriers
Paperwork and a lot of incoming information
The validation process is accompanied by a series of required information and documents, which is higher than before. Due to the high volume of work of the personnel in the departments, this causes a lot of time to be spent by the personnel and the patients are neglected.
“The truth is there is so much trouble. But in terms of practical a series of measures were done that are so good. Now it is the cumbersome. But it was added series paperwork so, makes us to neglect of the patients. Useful times are lost to do these works. I don’t hate myself to do these things, like completing the blood reservation sheet. But there are so many sheets.“(P10).
Head midwife stress and concern for accreditation
The responsibility for the correct implementation of accreditation indicators in the units is with the heads of the units, and the managers and officials of the hospital expect the correct implementation of the accreditation in the units from the head of the unit, which may cause stress and anxiety. The anxiety of the lower and middle managers of these departments to complete the standards causes anxiety in the personnel of these departments in participating in the accreditation.
“If the staffs do not do a job or don’t answer a question, finally I have to answer myself, otherwise we will be reprimanded.“(P2).
Inappropriate staff attitude toward accreditation
The majority of staff have a negative view of accreditation and have a perception that it is a wasteful and time-consuming task. There are several reasons for this and it requires training and a culture change among the staff.
“ The attitude of employees towards crediting has changed by 10 to 20%. But the promotion of culture must be done properly. You look elsewhere, the midwives’ view of clinical governance is not good.“(P7).
Reducing the motivation in the midwife
The huge difference in salaries and benefits between midwives and doctors has reduced the motivation among women’s department employees, especially midwives. They have no motivation to carry out accreditation measures and this disrupts the implementation of accreditation in the maternity department.
“Yes, right now the midwifes are much complained for the tariffs. Us midwifes do urinary catheterization, angioket and…. then, gynecologist go behind the computer and record tasks for themselves! 3 dollars for each emergency visit, this is the social differentiation. This leads to reduce nurses’ motivation. These cases are like a fire under the ashes, imported much harm to nursing.“(P8).
Midwife feel forced to do accreditation
Emphasis on the implementation of accreditation standards and its strict implementation by hospital managers, regardless of financial or work incentives, has made midwives feel pressured and forced to perform accreditation.
“there is pressure on nurses to do accreditation tasks and the relevant controls in other groups medical, we must control our own colleagues, the doctors, and the clinical unit and…. These works are mandatory.“(P10).
“ Night shift workers are more involved in the story of accreditation. Because all of inspections done in the morning shift, Evening and night shift staff somehow think some of this morning’s works is imposed on them now. It is principle come to inspection in all sheets.“(P5).
Resistance to change
Accurate completion of standards requires changes in many habits and behaviors of personnel in clinical and teamwork dimensions. Change among staff is always accompanied by resistance. Carrying out many validation measures requires making changes in the usual processes in the departments, and these changes are accompanied by resistance from the personnel.
“Many personnel do not work in the public hospitals. Resistance to change is mostly related to cultural reasons.“(P13).
Accreditation facilitators
Actual facilitators
The availability of in-service training courses
During the year, several in-service workshops for clinical staff and hospital administrators are organized by the Ministry of Health, university, and hospital to learn how to complete accreditation standards. These workshops are done separately from the management levels and the expertise of the employees involved in accreditation. These workshops are a good opportunity for midwives to learn the latest accreditation standards and how to complete the highest quality. This workshop reduces midwifery anxiety in completing validation standards in the maternity department.
“Although most of the lecturers are nurses’ accreditation workshops, we learn how to complete the accreditation faster, easier and more accurate methods in each workshop, These learning reduces our anxiety and anxiety in completing the standard quality in the maternity departments.” (P10).
Determining the errors and clarification activities with documentation
Since the patient has the highest standards in accreditation, it is of great importance to the Ministry of Health. Establishing a Patient Safety Committee and the Quality Improvement Office by collecting the necessary data on drug/non -pharmacological errors and medical services provided to pregnant women in the maternity departments identifies and provides a model of common errors and regulates prevention strategy.
“ Our mistakes in completing accreditation standards will be reported to our department manager in a period of time and categorized by the Quality Improvement Committee… By reviewing these reports, our mistakes have declined in many areas and the speed of completing our standards is high.” (P8).
“Because the safety of the mother and the baby is very important, all the drug, therapeutic and careful errors are analyzed, and the report and the strategies of not repeating them are explained to us as a group in the section by the responsible midwife.” (P10).
Clinical midwifes’ involvement in decisions of the accreditation
As the leadership team has a member from all parts of the hospital, the midwife’s participation in the maternity department has made it more complete and specialized. Membership in this team has increased the motivation of midwives to complete the provisions of the delivery.
“ In the last three years, in the accreditation team from the maternity department, one person was added as a member of the accreditation team.…It gives a person a sense of worth” (P7).
Risk reduction and job security
Considering that one of the important reasons for midwives to quit or be fired from their jobs is medical mistakes, increasing patient safety standards in accreditation has reduced medical errors. The high number of patient safety standards by reducing dangerous and low-risk errors has reduced job stress and high job security for midwives.
“In addition to the heavy workload that it creates for us, accreditation also has some advantages, with its strong emphasis on patient safety, it reduces our errors and thus protects us from being reprimanded and losing our reputation.” (P6).
Potential facilitators
Hope for a better future with the accreditation process
Hardware and software structural changes in hospital parts due to accreditation standards have improved many processes in hospitals. The increase in medical and non-medical equipment has facilitated many processes due to the requirement to implement accreditation standards. From the point of view of midwives, these changes are promising to create changes in other dimensions, such as teamwork, improving job satisfaction, working atmosphere, welfare facilities, and appointing competent managers.
“ We hope that in the coming years, as much as accreditation emphasizes on the patient, it will also have standards on the personnel of the departments, so that our work situation, such as job discrimination and poor teamwork of the rest of the team, will be less. " (P11).
Satisfaction of the accreditation, transparency
From the midwifery point of view, accreditation standards should create more transparency in therapeutic protocols, processing, and documentation. Increasing transparency leads to a decrease in ambiguity and confusion among midwives in the maternity departments.
“In many cases, there is a perception and definition between different managers… Disagreement causes confusion and increased workload.” (P4).
Emphasis on efficiency and effectiveness
From the point of view of midwives, accreditation standards should create effectiveness in terms of the human and physical resources of hospitals. They hope that the standards will prove the effectiveness of midwives’ skills in the maternity departments and other management areas of the hospital.
“We hope that our skills will be seen by the managers of the hospitals… When one of the midwives is selected as the supervisor of the hospital departments, our existence and our skills will be effective.” (P3,6).
Discussion
In this research, obstacles and facilitators of accreditation in the Department of maternity departments were investigated and identified from the perspective of midwives. The identified barriers included managerial, administrative, and personal barriers and the identified facilitators included actual and potential facilitators. The identified actual facilitators include the availability of in-service training courses, identification of errors and clarification activities through documentation, participation of clinical midwives in accreditation decisions and risk reduction and job security, and identified potential facilitators include hope for The future is better with validation, satisfaction with validation and transparency and emphasis on efficiency and effectiveness.
Management factors and the type of leadership are the most important predictors of effective accreditation, and executive factors have the greatest impact on accreditation results [23]. The results of Kafashpoor et al.‘s study in Iran also showed that executive factors are the most effective accreditation factors [24]. Lack of proper policy by managers and providing sufficient platforms including financial resources and facilities are among the problems of validation implementation [25]. In a study by Algunmeeyn et al. (2020) in Jordan, 4 key barriers were identified lack of motivation, low salary, high workload, cost of implementation of accreditation, lack of staff, and high turnover of staff for hospital accreditation [26]. In the study of Nekoei-Moghadam et al. (2018) in Iran, it was also found that the current accreditation program is not proportional to the number of available personnel [27]. Because the lack of human resources causes organizations to not achieve their accreditation goals [28]. Another obstacle identified in this research is the lack of necessary organizational culture among hospital employees and managers, and especially the lack of accompanying doctors in the field of accreditation. The participants in this research believed that both managers and employees do not give due importance to accreditation and look at it as an additional, unnecessary thing and they try to gain by pretending and not by real actions. Scores are required for accreditation. Regarding the non-participation of doctors in validation, it has been reported that there is no necessary culture among doctors to participate in group work such as validation. Also, doctors feel that accreditation is ceremonial work, so they don’t want to participate in it [29]. In the study of Bahadori et al. (2015) it is pointed out that not all occupational groups in the hospitals are involved in the accreditation, most of duties and documentations are the responsibility of nurses, and physicians generally do not play any role [30]. The lack of cooperation of doctors in the implementation of accreditation guidelines and the lack of responsibility towards it has also been observed in other studies [1, 31]. The results of Vali et al.‘s (2020) study also showed that accreditation is idealistic, time-consuming, and lacks economic efficiency, it does not match the conditions of the hospital, including the high workload, and ultimately, it does not change the performance of the hospital and patient satisfaction [25]. In Alkhenizan et al.‘s (2011) study, the results showed that about 70% of the managers who participated in the research believed that accreditation is not worth spending money and time on [32]. The results of this study show that the salaries and benefits received by them have reduced their work motivation and willingness to cooperate in accreditation. In Algunmeeyn et al.‘s (2021) research, nurses, and doctors stated that appropriate salaries and incentives improved staff performance and helped them pass the accreditation successfully [26]. Other obstacles identified by the participants of this research are the time-consuming and the imbalance of the accreditation process with the tasks during the shift, the paperwork of the accreditation process that causes a lot of time and neglect of the patients, the resistance of the staff to change and the stressful nature of accreditation. In the study of Tashayoei et al. (2020), excessive emphasis on documentation and obtaining points only through documentation were identified as the most important obstacles to accreditation [33]. Providing a large amount of documentation by clinical staff and placing a heavy emphasis on documentation imposes a large financial burden on hospitals. In addition, this issue takes a lot of time from employees and causes many policies not to be implemented in practice [34]. In addition, the proper implementation of the accreditation process, which is considered stressful by employees, requires serious budgeting and planning [27]. In the study of Al Mansour et al., it is pointed out that planning is the first step to achieving accreditation goals by which hospitals can make changes in infrastructure, documents, and employee culture. However, the implementation of planned changes is more difficult and is often faced with employee resistance, which is caused by time constraints, lack of employees, workload, and stress on employees [35]. In the study of Janati et al. (2016) the issue of excessive documentation and lack of attention to the bedside in busy and busy departments is mentioned as one of the challenges of accreditation [31]. In the study of Greenfield et al. (2011), one of the important challenges of accreditation is involving and creating The motivation among doctors and medical staff to participate in the validation was partial. Also, the employees expressed concern about the interaction with the evaluators. They were afraid that they would not be able to adequately answer or remember the details of the questions they were asked [36]. The results of the systematic review study by Tamata and his colleagues show that ineffective regulations and strategies, weak policies and weak plans, ineffective implementation of programs, insufficient labor recruitment, and continuous changes of government managers were the main factors affecting the nursing workforce shortage [37]. The lack of cooperation of doctors in the implementation of accreditation guidelines and the lack of responsibility towards it have also been observed in other studies [1, 31]. The results of the study of Lotfi Hadi Biglo et al. showed that nurses who have more experience and knowledge have a positive view of accreditation and consider it effective in improving quality of hospital care [38]. Therefore, it seems that the organizational culture of participation in accreditation can be improved by increasing the awareness of nurses regarding the effects of accreditation.
Research participants listed efficiency and effectiveness as factors that facilitate accreditation. In Melo’s study (2016), the interviewees stated that the accreditation process helped to improve the quality and patient safety and played a key role in creating a culture of patient safety in the hospital [39]. The results of Sharifi et al.‘s study in Iran also showed that accreditation program execution in hospitals strengthens cultural and structural factors, systemic-management, and human resources. Participants believed that accreditation promotes cultural and structural factors in the hospital through improving organizational structure [40]. In the study of Algunmeeyn et al. (2020), the four key advantages of accreditation in the studied hospitals from the point of view of healthcare workers were quality improvement, patient satisfaction, patient safety, and cost-effectiveness [1]. Of course, there are contradictory results regarding the effectiveness of accreditation in various articles. For example, a study by Brubakk et al. (2015) found no evidence to support the accreditation and certification of hospitals with measurable changes in quality of care as measured by quality measures and standards [9]. In the systematic review study by Alhawajreh et al. (2023), it was also found that the findings about the impact of accreditation on improving the quality and outcomes of health care are contradictory and there is little evidence about its effectiveness [41]. Other identified facilitating factors included the availability of in-service training courses, determining errors and clarification activities through documentation, participation of clinical midwives in accreditation decisions, reducing risk, job security, and hope for a better future with accreditation. In Karimi et al.‘s study (2013), it was found that accreditation has a positive effect on service quality through documenting and standardizing processes and increasing the culture of participation and teamwork [42]. Nekoei-Moghadam et al. (2018) emphasize that proper training of employees and reducing their fear of the accreditation program promotes the culture of quality management and patient safety and solves many accreditation problems [27].
Conclusion
Barriers to completing accreditation are multidimensional. The lack of proper management to create a cultural structure, to involve members of the treatment team, to solve the lack of staff, conflict between hospital standards and accreditation standards, frequent manual documentation, lack of anxiety control and promotion of motivation are some of the barriers to completing accreditation. Having multiple in-service courses related to accreditation and categorized errors and emphasizing effectiveness is a facilitator of accreditation completion. Considering the importance of the mother and newborn, health managers should adopt short and long-term management policies in the maternity departments to improve the facilitating factors and remove the barriers. To control the erosiveness of the accreditation process, the high-level managers of the hospitals should teach midwives effective management methods, the active participation of gynecologists, increase motivation with financial and administrative incentives, involve more midwives in committees, and increase the personnel involved in the accreditation process. The middle managers of the hospital should also coordinate and balance the number of clinical shifts with the number of shifts in the accreditation process team. Planning in-service training to explain and inform about how to accurately complete accreditation standards and classification activities to reduce work errors.
Implication for practice
Considering that the goal of the accreditation process is to improve the quality of patient care, our top managers should implement short and long-term strategies such as implementing incentives to increase motivation and improve teamwork with the participation of all members of the medical team and reduce workload and adopt the anxiety of the accreditation team in the maternity department.
Acknowledgements
The authors are extremely grateful to the Vice President of Research, School of Nursing and Midwifery, Qom University of Medical Sciences and all the participant who participated in this study.
Declarations
Ethics approval and consent to participate
This research was approved by the National Committee for Ethics in Biomedical Research and the Ethics Committee of Qom University of Medical Sciences, Qom, Iran (approval code: IR.MUQ.REC.1401.236). Participants were informed about the study aim, the voluntary participation, and the right to withdraw from the study. Formal informed consent was obtained from all participants on the day of the interview. All steps of this research involving human participants were conducted in accordance with the research principles of the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Clinical trial number
not applicable.
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