Proposing a Framework for Accreditation of Dental Clinics in Iran

INTRODUCTION

Accreditation seeks to ensure the provision of quality, safe and up-to-date scientific care services (Al-Jazairi et al., 2021) and is one of the most important areas in the evaluation of health services. Accreditation is defined as "the certification of a health care provider's achievement of predetermined standards by an independent external peer review team from the same organizational leve (Tabrizi et al., 2012)". The accreditation process is such that the reputation, credibility, and formality of a health care provider organization for performing certain services according to the standard is verified by an accreditation group or organization. This evaluation includes examining the quality of organizational processes. The performance of the organization will be in accordance with the written and approved standards that have been developed by experienced and specialized people (Raeisi et al., 2008; Yarmohammadian et al., 2013) and will usually be accompanied by awarding to the organization that has complied with these principles (Toplis, 2002).

The purpose of accreditation in health organizations is to improve the quality of health services, improve integration in health service management, create a database of health service organizations, increase safety and reduce risks for patients and staff, training and counseling for health service organizations and reduce costs with a focus on increasing efficiency and effectiveness (Jafar & Farid, 2012; Tabrizi et al., 2012; Al-Alawy et al., 2021; Badauod et al., 2021). Accreditation should encourage responsiveness to opportunities rather than program compliance, and its costs should be cost-effective and commensurate with the value received. It must also be autonomous and independent of the undue influence of any individual, organization, or group (ADEA, 2012).

Jean 2019 concluded in its study that accreditation is an important part of the legislative framework because it is the only legal instrument that can identify invalid standards without the need for a complainant. Patient safety is at the forefront of oral care, and the dentist strives to minimize errors and facilitate quality improvement. Accreditation can help achieve these goals and reassure consumers that the treatments offered at dental clinics are safe and good quality (Jean, 2017). Dentistry is an important part of the health care landscape and cannot be exempted from a commitment to provide quality care. Limited research has been conducted on accreditation programs for dental clinics (Mills & Batchelor, 2011; Ramoni et al., 2012; Al-Jameel,  2021) and there is no conclusive evidence that accreditation across the healthcare sector has a significant impact on improving safety and quality in healthcare (Braithwaite et al., 2010; Hussein et al., 2021).

Accreditation standards have been developed in hospitals, and clinics, but the important thing in an outpatient dental clinic is to coordinate and conform to these standards, as well as to see all the technical or medical, managerial, and logistics aspects. The present article discusses how to combine these three standards and provide a structure for the accreditation of dental clinics in Iran.

MATERIALS AND METHODS

This study was performed in a qualitative method. Comparing the dimensions of the models and developing an initial model using three separate models and combining them, a model was designed for Iranian dental clinics. These three models are:

1. National accreditation model of Iranian hospitals (to set the general framework and the pair of accreditation standards)
2. Proposed model of accreditation of Iranian boarding clinics (to set the general principles of accreditation of outpatient clinics)
3. Proposed standards in previous studies for dental clinics (to regulate dental technical issues)

After collecting and analyzing the necessary information, the framework of the accreditation model was designed. It was then polled through an FGD. According to the experts' opinions, the final model was presented. All group discussions were conducted using a semi-structured guide. In addition to the researchers, there was a coordinator, an observer, and a note-taker in the FGD interview. It should be noted that the criteria for familiarity with the principles of accreditation, familiarity with dental processes, the experience of executive activities, and expertise in the fields of dentistry, management, and health were used to select experts. In this study, four group discussion sessions were held with the presence of key informants. The duration of these sessions was about 45 to 60 minutes. The FGD questionnaire was designed with three specific objectives, which included the following three objectives.

1. Study and comparison of hospital and outpatient accreditation standards in Iran and accreditation standards in dental clinics of other countries
2. Determining the main categories of accreditation of dental clinics in Iran and
3. Determining the subcategories of accreditation of dental clinics in Iran

The information related to the structure of the accreditation system of Iran and the selected countries was summarized and analyzed as much as possible in the form of tables. During the FGD sessions, the note-taker recorded the speech and at the same time, all the steps were recorded with the permission of all participants. Finally, all the notes of each session were reviewed and completed by the team members, then analyzed and categorized based on the objectives of the research.         

RESULTS AND DISCUSSION

A total of 11 participants in FGD, two managers of dental centers (18%), one dental specialist (9%), two health care management specialists (18%), one health engineer (9%), 5 supervisory managers of the University of Medical Sciences (46%). In this study, the categories of hospital and outpatient accreditation models were first examined.

To achieve the first objective of the study, first, the categories of hospital and outpatient accreditation models were examined, and also using the results of the study conducted by Alaghmandan et al. 2021, the main categories and subcategories of accreditation of dental clinics were extracted.

General Framework and Compliance with Accreditation Models

In this section, attention has been paid to the compliance of the framework with the previous ones, and the proposed framework has been paired with other accreditation models. Standards-producing organizations try to conform to previously established standards so the body of the organization is more familiar with them and can better implement this standard at the same time. Like the ISO 9000 and ISO 14000 standards, where ISO 14000 was paired with ISO 9000 so all organizations that want to run both organizations can easily use both. We also used this idea in our study and wanted the framework of dental accreditation clinics to be compatible with other accreditation models, i.e. their overall structure is similar. Because our health system is familiar with this structure and we prefer the accreditation framework of dental clinics to be the same.

The accreditation model of Iranian hospitals, including 37 categories and 8104 standards, was developed by the Ministry of Health in 2010 and notified to hospitals for implementation. The first accreditation evaluation of the country's hospitals was conducted in 2012 by a team of 20 to 25 accreditation evaluators of medical sciences universities. A large number of standards, the lack of transparency of the standards, and their equal weight created challenges for hospital managers and staff during implementation. As a result, the second edition of the country's hospital accreditation, including 36 categories and 2157 standards, was notified to hospitals in 2015 (Mosadeghrad & Nabizade, 2018). Hospital accreditation in Iran has reached the fourth generation so far. Because it is important to coordinate any new standard in the field of accreditation with this basic model in the country, we tried to harmonize the general framework of the dental accreditation standard with this model. The main categories in the fourth generation of hospital accreditation in Iran are presented in Table 1.

Table 1. The main categories and subcategories of the hospital accreditation model in Iran

Setting the Logistics Categories of Outpatient Clinics Accreditation

These standards were developed at the request of the Ministry of Health in 2016 and were provided to the Ministry, which, of course, has not yet been officially announced. Because a dental clinic, like any other outpatient clinic, has logistics departments, we tried to use the logistics categories in our framework. Table 2 presents the categories model of accreditation of outpatient clinics in Iran.

Table 2. Logistics categories in the accreditation model of outpatient clinics

Technical Issues of Accreditation of Dental Clinics

To develop the technical and medical categories of dental clinics accreditation, the integrated model obtained by the same team was used in a comparative study that was confirmed by the Delphi method. This model has 84 standards for accreditation of dental clinics, which are classified under 10 main categories, which are presented in Table 3.

Table 3. Main categories of the proposed accreditation model

Finally, after reviewing the above models and to achieve the second and third objectives of the study in 4 sessions of FGD members, 4 main categories include leadership and management, care and treatment, rights of service recipients, and quality specialized services presented as the accreditation framework of dental clinics in Iran, because these categories are part of the main pillars in almost all accreditation models. And other related categories were placed as subcategories. In this study, the FGD decided to create a special category called the quality specialized services of dental clinics and to examine access to care, access, and continuity of dental care. In Table 4, all the categories and subcategories of the proposed framework are presented.

Table 4. The final framework of accreditation of dental clinics

Studies on the effectiveness of quality management programs for dental care practices can make an important contribution to the evidence-based quality of oral services as well as improving patient outcomes. Oral health services must be equal to other health services in terms of quality management (Bader, 2009; Crisan et al., 2021). Limited research has been conducted on accreditation programs for dental clinics (Mills & Batchelor, 2011; Ramoni et al., 2012). The United Kingdom and Denmark have now recognized that the accreditation of dental programs should not be based on the same standards for hospital accreditation, and a separate set of standards should be developed accordingly (Care Quality Commission, 2015; IKAS, 2017). In Australia, the Royal Australian College of General Practitioners (RACGP) has taken a similar approach to accrediting dental services (RACGP, 2014). Jean's study 2019 showed that the accreditation standards of dental clinics should be as concise as possible and easy to implement (Jean, 2017). Therefore, in this study, we tried to simplify the proposed framework by integrating important categories as much as possible.

Management and Leadership

Good leadership and management are important for the success of any organization. In a health care organization, good leadership and management are more important (Manojlovich, 2005; Reeleder et al., 2006). This is very important for the success of the organization. The accreditation system has significant effects on professional culture and leadership in the organization and improves the efficiency and performance of the hospital and staff morale by using appropriate management strategies (Woo et al., 2018). Accreditation continues to improve the quality and performance of the organization's services (Saremi, 2018). Extensive use of information and communication systems by health organizations has necessitated the evaluation of such systems. Understanding the successful implementation of hospital information and communication systems is critical to improving health care services (Bürkle et al., 2001; Palm et al., 2006). The 2017 study by Vahdati et al. Showed that empowerment of human resource management based on accreditation standards significantly affects the quality of health services (Vahdati et al., 2017). In the proposed accreditation structure of dental clinics, according to key informants opinions, it was decided that all the logistics unit categories considered in the accreditation models should be provided under this category, which includes subcategories (quality management, accident, and disaster risk management, human resources management and occupational health, technology and health information management, environmental health and resource management).

Patient Care

Mills et al. 2014 concluded in their study that patient-centered attention as a fundamental principle in the provision of dental services is often overlooked and that patient-centered standards in the provision of these services need to be pursued more seriously (Mills et al., 2014). Therefore, this category was added to the proposed model, which included subcategories (general clinical care, acute, and emergency care, surgical and anesthesia care, and drug management). A global problem in all health organizations around the world is infection control. A 2012 study by Laheij et al. Shows that the risk of transmission of infection by bacteria and viruses in the dental environment is of particular importance. This article concludes that transmission and infection with hepatitis B virus pose the greatest risk to the dental team and patient (Laheij et al., 2012). Therefore, the infection control subcategory was added to this main category.

Rights of Service Recipients

One of the main categories in all accreditation programs is paying attention to patients' rights. Patients' rights are taken into account in accreditation; It may also provide effective tools for policymakers and patient support groups to inform physicians, patients, and their families about such rights and to promote and enforce them in the health care system (Sperling & Pikkel, 2020). Therefore, in the proposed framework, this category was divided into two subcategories: providing facilities for the service recipient and respecting the service recipient's rights, in which all patients' rights are considered.

Quality specialized services

Promoting continuity of care is essential in improving the delivery of health services (Amelung et al., 2017). Continuity of care is defined as a set of separate health care events provided by individuals in a coherent and interconnected manner over time and in accordance with the patient's health needs and preferences (World Health Organization, 2018). This category, which included the subcategories of access to care, evaluation, and improvement, and continuity of care, has been created to meet the needs of the patient in the health care organization. It also created the process of providing continuous services to patients by providing the possibility of coordination and continuity of services to patients.

CONCLUSION

This study showed that by combining three models of outpatient and inpatient accreditation in Iran and outpatient accreditation models in the top countries, a comprehensive model for accreditation of dental clinics in Iran can be achieved. One of the features of this model is the compatibility of the model with other accreditation models in Iran, which causes us to see a few challenges in implementing this model. In developing this model was tried as much as the possible concise but comprehensive model.

ACKNOWLEDGMENTS: The research team would like to thank all the people who participated in the FGD sessions and provided valuable feedback.

CONFLICT OF INTEREST: None

FINANCIAL SUPPORT: None

ETHICS STATEMENT: None