Determination of Gap in Accreditation Standards Establishment Process Using Zachman Framework at a Health-Educational Hospital

Abstract

Background: Accreditation is usually a voluntary plan supported by a non-governmental institution and trained evaluators that examine the competency of organizations providing health service according to pre-specified performance standards. Objectives: The current study aimed to determine the degree of establishment of accreditation standards using logical framework of Zachman. Methods: This descriptive research was conducted during year 2015. The population of the study included people involved in the establishment of accreditation standards. Sampling was conducted in the form of complete enumeration according to 36 standards of accreditation. The instrument used for data collection was the “Logical framework of Zachman”. Columns of framework consisted of people involved in conducting the work (Who), the purpose of the work (Why), strategy of the work (What), work time (When), and sub-system of doing work (Where) and way of doing work (How), and rows of framework included the view of hospital chief, director/assistants of hospital, officials and personnel. Test chi-square was used to compare between accreditation standards text and studied hospital gap. Descriptive statistical method was used for variables. Results: People involved in doing work and sub-systems of doing work at the hospital were consistent with specified accreditation standards. In 27% of the standards, time interval of doing work in the hospital was not conducted according to accreditation standards. In terms of way of doing work, 25% of standards had not been established, and 26% of them had been established incompletely. During interviews, it was found that 59% of personnel of purpose of doing work, and 94% of them are not informed about the strategy of doing work, according to accreditation standards in the hospital. Conclusions: Uncertainties in the accreditation standards in dimensions of purpose, people involved, strategy and time interval of doing work, respectively, led to a lack of understanding the intention of author/developers of standards by personnel. As a result, this led to lack of complete establishment of accreditation standards in the studied hospital. Keywords: Accreditation, Establishment, Gap, Hospitals, Tehran