Codification of National Accreditation Standards for Management and Leadership in Hospitals of Iran

Background and purpose: Providing excellent patient care requires effective leadership. The aim of this study was to codify accreditation standards based on scientific evidences and local conditions for management and leadership in hospitals in Iran. Materials and methods: In this applied study the codification process lasted for three years (2007-2010) and several activities were done in different stages. They were reviewing the accreditation standards of selected countries, reviewing the standards of Iranian hospital evaluation, forming expert panel and determining the type of accreditation model, preparing a standard draft and feedback form, organizing symposium and expert panel, performing a pilot study, holding workshops and subsequent revisions, codification and notification standards. Results: National hospital accreditation standards for leadership and management in Iran consists of 9 categories and 151 standards (65 clauses, 86 sub clauses) including governance, executive, chairman- managing director, hospital administration, management of educational and research activities, risk management, crisis/disaster management, failures and adverse events, and financial management. Financial management included most of the standard clauses (24 clauses and 23 sub clauses). Conclusion: Hospital managers play an important role in developing hospital accreditation standards in different wards and departments (clinical and non-clinical), patient safety, and quality improvement