محمدعلی فتوحی

Hospital accreditation is used as a tool to improve the quality and safety of patients. The effectiveness of accreditation depends on the content of the standards. Considering the role of executive management team of hospitals in the implementation of accreditation standards, this research was conducted with the purpose of evaluating the viewpoint of executive management team of hospitals of Qom province in terms of the third generation of accreditation of hospitals.
This descriptive cross-sectional study was carried out in 2017 using a questionnaire in 5 sections. The statistical population consisted of the executive management team of all hospitals in Qom province, which was selected by census method. Data were analyzed by descriptive and inferential statistical methods.
The level of agreement of the executive management team of the hospitals with the sections of content, implementation, and the effects of accreditation was in the medium range and in terms of methodology and expectation of the accreditation was in the agreement range. The highest agreement was reported with the expectation section and the lowest agreement was with the implementation of the accreditation standards.
The results of this study showed that elimination of deficiencies in the structural resources of hospitals, removal of uncertainty about the scale, the weight of the evaluation scores, the coordination and unity of procedures among accreditation assessors, and the effort to attract more physicians, can be effective in achieving the goals of accreditation of hospitals.

performance evaluation is an important tool for measuring achievement of an organization’ quality objectives and performance excellence. Among the models of organizational excellence currently used to evaluate the quality of services in hospitals, European Foundation for Quality Management (EFQM) have been more welcoming in hospitals. This study was done with the aim of evaluating the performance of Qom shahid beheshti hospital based on EFQM excellence model and identification of strengths and areas in need of improvement. This study was conducted using cross-sectional method during summer 2011. The Tool for data gathering was a standard self-assessment questionnaire based on EFQM excellence model. The study population was staff managers of Qom shahid beheshti hospital, who were selected through census method. Data were collected in the form of nonuplet criteria of EFQM model, and analyzed by descriptive tests. The scores that were obtained based on nonuplet criteria of EFQM were as follows: 48.4% for leadership, 44.9% for policy and strategy, 48.6% for employees, 49.5% for resources and contributions, 46.4% for processes, 42.1% for the results of customer, 38.6% for the results of employees, 44% for society results, and 42.4% for key performance results. The highest and lowest scores were related to resources and contributions and results of employees, respectively. Total scores of the hospital were 447 out of 1000. Considering that the assessment process of board of trustees hospitals is using EFQM evaluation model in addition to accreditation standards, therefore, in this research, the strengths and weaknesses were identified using this model and some recommendations were given to the hospital.