The experience of 10 years of institutional and program accreditation in Iran with an emphasis on the strengths and implementation challenges: a qualitative study

Abstract

Background

The global emphasis on medical education quality has established accreditation as a crucial evaluation method. Iran has implemented systematic institutional and program accreditation in medical universities over the past decade. This study analyzes the strengths and implementation challenges of educational accreditation from the perspective of field experts.

Methods

We conducted a qualitative content analysis study, engaging accreditation experts selected through purposive sampling. Semi-structured interviews were employed to gather expert opinions on the strengths and challenges of implementing educational accreditation in Iran. The resulting data underwent inductive content analysis to distill key themes and insights.

Results

Analysis of the interviews yielded 140 primary codes, which were organized into two main themes and six categories. The first theme, “the Pillars of the Accreditation System,” encompassed four main categories: accreditation standards, accreditation structure, accreditation evaluators, and accreditation outcomes. The second theme, “Improvement in Conducting Accreditation,” comprised two main categories: improving the structure and improving the implementation process. While accreditation efforts have improved institutional adherence to basic quality standards, challenges such as excessive governmental control and the approval of underperforming institutions raise concerns about the credibility of the process.

Conclusion

The efforts of the Ministry of Health and Medical Education in implementing accreditation have guided programs and institutions towards achieving minimum quality assurance standards. Structural issues within Iran’s accreditation framework, such as governmental control over the accreditation process and the consideration of multiple factors in accreditation decisions, have led to some concerns. One of these concerns is approving underperforming institutions and programs which has raised some questions about quality and necessity of the accreditation process itself. It is hoped that in the near future, the Ministry of Health and Medical Education will devise and implement strategies to enhance the current system, paving the way for a more robust and effective accreditation process in the future.

Background

Accreditation plays a crucial role in improving the quality of education by balancing the preservation of educational values with continuous quality enhancement, while also ensuring that institutions meet societal needs [1, 2]. This process, based on self-evaluation and peer review, ensures that institutions meet the standards set by accrediting bodies, upholds university values, and protects institutions from political interference [3, 4]. It also helps the public recognize the quality of programs offered, signaling the institution’s commitment to ongoing improvement. Accreditation of medical education institutions should ultimately enhance health services, and the care provided to patients [5, 6].

Numerous articles have been published worldwide regarding the impact of accreditation on increasing the educational quality of institutions and programs and stakeholder opinions of the process. For example, Lewis’s qualitative research aimed to determine university faculty members’ perceptions about the accreditation of educational institutions in the US. The results indicated that despite not receiving rewards for performing accreditation-related tasks, professors understood the value of educational accreditation and devoted considerable time to related tasks. Academic staff members comprehended the value of program accreditation, its recognition, and reflection in the curriculum, believing that accreditation can lead to curriculum improvement [6].

Another qualitative study by Soudi at a California community college showed that participants’ negative perceptions created challenges in interpreting and using institutional accreditation standards. The study provided recommendations to improve the compatibility between understanding and applying the standards, enabling institutions to demonstrate better performance for student success [7].

In Iran, Chehrazad et al. classified negative perceptions of the accreditation system in medical institutions and educational centers into three categories: “challenges related to the university’s cultural context,” “challenges of the university structure,” and “challenges of the educational accreditation plan”. They also introduced an executive model to reduce weakness in the implementation of educational accreditation [8].

Universities of medical sciences in Iran have special characteristics. One of the main features is their guardianship by the Ministry of Health, Treatment and Medical Education, which is simultaneously responsible for education, evaluation of education, and assessment of educational performance. Another significant characteristic is the rapid growth in the number of medical sciences universities, established in response to the increasing demand for health services. This accelerated growth in the number of medical sciences universities and the diversity of fields over the past decades have encouraged those involved in the country’s higher health education system to increase their focus on preserving and improving the quality of education, research, and service provision.

In Iran, the Ministry of Health, Treatment and Medical Education has adopted the accreditation model to evaluate the quality of education. This procedure has been systematically implemented since 2015, simultaneously with transformation and innovation initiatives in higher education [9].

Considering the impact of accreditation on the quality of education in institutions and programs, it is crucial to address the challenges and obstacles to its implementation and strengthen its positive aspects. This approach will enable educational institutions and programs to take more effective steps to improve their performance by using accreditation standards. Given this consideration, this study aimed to determine the strengths and challenges of educational accreditation implementation from the perspective of experts in the field of educational accreditation, focusing on the experience of 10 years of institutional and program accreditation in Iran.

Methods

Study design and approach

This study employed a qualitative descriptive approach utilizing inductive content analysis to elucidate the strengths and challenges in implementing educational accreditation from the perspective of experts in Iran. Content analysis, a systematic and purposeful method for describing phenomena [10], was chosen as the primary analytical framework.

Participants and sampling

The method of sampling was purposeful by selecting experts in the accreditation, which was followed by snowball sampling method. The selection of experts was done by accreditation officials. Interviews with participants continued until no new code was added to data and data saturation was reached. Inclusion criteria encompassed responsibility in accreditation implementation or standard/bylaw development, while exclusion was based on unwillingness to participate in the interview process. The sampling strategy aimed to maximize diversity in terms of gender, field of study (clinical or non-clinical), and periods of participation in accreditation process (institutional or program).

Data collection

Data were collected through in-depth, semi-structured interviews. The interview questions were developed based on researchers’ experiences and were revised after the first interviews. The questions and interview transcript were in Farsi language. The interview guide including the questions was distributed to participants along with an informed consent form via email or social media. This form detailed the research purpose and assured data confidentiality. Interview scheduling was coordinated with participants, and all sessions were recorded with participants’ consent. Interviews commenced with an open-ended question about the participant’s role in educational accreditation, followed by subsequent questions guided by the interview framework. The goal was to explore perspectives of experts from weakness and strength of accreditation system in Iran. To minimize bias, efforts were made to create an environment where the interviewee felt comfortable expressing their opinions. Additionally, the interviewer refrained from offering any verbal or non-verbal confirmation. The researchers probed deeply into various aspects of the accreditation system in Iran, including:

• Perceived strengths and weaknesses.

• Confidence in accreditation results.

• Implementation challenges and potential solutions.

• Necessity of accreditation implementation.

• Characteristics of educational accreditation in Iran.

• Achievement of accreditation system objectives.

Each interview lasted between 35 and 65 min.

Data analysis

Interviews were transcribed immediately post-interview. The text of each transcript was confirmed by participants to assure that their opinions were accurately captured. The analysis process involved:

• 1. Multiple readings of each transcript to ensure comprehensive understanding.

• 2. Extraction of semantic units from each interview text.

• 3. Summarization of most semantic units and initial coding.

• 4. Categorization of extracted codes into subcategories and classes based on semantic similarities.

• 5. Abstraction process to elucidate the main study themes.

Trustworthiness

To ensure the validity and robustness of the findings, Lincoln and Guba’s four criteria were applied [11]:

• 1. Credibility: Enhanced through prolonged engagement with the research topic and triangulation of multiple researcher perspectives. Maximum diversity among participants—considering gender, study field, and accreditation experience—also strengthened the credibility. The interviews were coded and analyzed by two independent coders.

• 2. Dependability: Established via external audit, where coded interviews were reviewed by an external observer.

• 3. Confirmability: Achieved through participant review of data and research audit.

• 4. Transferability: Supported by providing a detailed research plan, participant selection method and characteristics, data collection and analysis process, and rich findings with appropriate quotations.

Ethical considerations

To comply with ethical considerations in this study, IRB approval was obtained. The purpose of the study was first explained to the participants and an interview guide was prepared and shared with participants detailing research objectives and data confidentiality assurances. Informed consent was obtained from participants, both for their involvement in the study and for recording their voices. To protect anonymity and confidentiality, all names and identification codes were removed from the interview data.

Results

Participant characteristics

The study included 13 participants (2 females, 11 males) comprising both clinical and non-clinical faculty members with expertise in accreditation. Table 1 presents the demographic distribution of the participants.

Table 1 Characteristics of the participants

Thematic analysis

The analysis yielded 140 initial codes, which were subsequently categorized into 22 subcategories and 7 categories. These were ultimately synthesized into two main themes: [1] The pillars of the accreditation system, and [2] Areas for improvement in accreditation implementation. Table 2 presents the complete thematic structure.

Table 2 Thematic structure of Educational Accreditation in Iran

The pillars of the accreditation system

This theme encompasses four fundamental components of the accreditation system: accreditation structure, accreditation standards, accreditation evaluators and outcome of accreditation. The expected outcome of accreditation is the improvement of educational service quality in institutions.

Fig. 1

The pillars of accreditation system

Accreditation structure

This category encompasses three distinct sub-categories: Accreditation Trustee, Accreditation System Implementation Instructions, and Conflict of Interest in the Accreditation Structure.

Participant Five offers insight into the evolving global perspective: “Initially, the prevailing notion was that the decision-making authority and vote-issuing body should be independent of the beneficiary. However, this is no longer considered problematic. Previously, it was argued that the Ministry of Health should not be responsible for accrediting its own sub-groups due to potential bias. Now, the perspective has shifted: under certain conditions, the Ministry of Health, which oversees both education and treatment, can indeed be in charge of its own accreditation process.”

Participant Seven presents a more critical view: “The summative effects of accreditation are essentially non-existent. If one were to suggest that accreditation leads to concrete actions, such as revoking accreditation where standards are not met, this simply does not occur… When the institution responsible for education development is also in charge of accreditation, such outcomes become improbable.”

A crucial aspect of the accreditation process is the clear communication of implementation guidelines to the programs and institutions undergoing accreditation. These instructions serve to ensure uniformity in the conduct of evaluations and the issuance of decisions. Participant Nine highlights a potential gap in this area: “While guidelines exist, one must question whether those in charge and at the helm of operations are fully cognizant of them. This issue permeates various types of accreditations; for instance, when procedural guidelines are established for program accreditation or other forms of accreditation, we often observe that the officials who should be accountable are entirely unfamiliar with the process.”

The final sub-category within this section addresses the critical issue of conflict of interest. From the participants’ perspective, this conflict manifests in both the executive processes and decision-making, as well as among evaluators tasked with arbitration and judgment. The existence of a conflict of interest can affect the accuracy of votes obtained from accreditation and reduce public trust in its results.

Participant One succinctly articulates the core problem: “The fundamental issue in our country is the dual role of the government as both the accreditation authority and the education provider. This inherently creates bias. “Participant Six elaborates on the systemic challenges: “We are burdened with bureaucracy and what I term the ‘grand pest’ of accreditation… Our accreditation system is embedded within the very system responsible for education delivery. These two entities have conflicting interests… This coexistence often leads to omissions, and consequently, our purported goal of quality improvement remains unfulfilled. Accreditation is a cornerstone of the education sector, yet it cannot be effectively achieved when the operational authority, policy-making body, and evaluating entity are one and the same.”

Accreditation standards

The current research elucidates several critical aspects of accreditation standards, as highlighted by the study participants. These aspects encompass the significance of a shared understanding of approved standards among internal and external evaluators and accreditation beneficiaries, the paramount importance of the standards themselves, their alignment with the prevailing conditions of the medical education system, and the necessity for periodic updates to reflect the cultural and social context of Iranian institutions and educational programs.

Addressing the need for contextual consideration and standard updates, Participant Three articulates: “Fundamentally, when we initially drafted the national accreditation program for general medicine, artificial intelligence was not a part of the landscape. Now, with the advent of technologies like ChatGPT, a revision is imperative…. It’s crucial to note that accreditation standards are not immutable; they can and should be modified to reflect current realities.”

Corroborating this perspective, Participant Ten emphasizes: “Standards necessitate regular review and revision based on evolving conditions. For instance, the standards for teaching hospitals have undergone two to three revisions. Similarly, the standards for the general medical program have been revised twice…”.

Accreditation evaluators

The accreditation evaluators’ category encompasses several subcategories: “Unity of action between evaluators,” “Regular training for evaluators,” “Conflict of interest of accreditation evaluators,” “Independence of the vote of accreditation evaluators,” “Considerations in conducting visits and evaluations,” and “Differences and individual characteristics of evaluators.”

Participants emphasize that regular training for evaluators is crucial for the proper implementation of accreditation processes and establishing consistency among evaluators. Participant Three notes, “Our colleagues in Isfahan employ consistent methodologies to assess evaluator capabilities. They’ve established training courses to align evaluators’ approaches”.

Participant Four highlights the importance of evaluator competence: “Evaluators must be highly capable, instilling confidence in those being evaluated and demonstrating their ability to improve institutional situations”.

Addressing evaluator differences, Participant Thirteen states, “Evaluation outcomes often hinge on the individuals conducting institution visits. Evaluators significantly influence the issued votes, which can lead to lenient assessments some of the assessor in spite of awareness of incomplete internal evaluation documents, provide faculties opportunities for complete documents”.

Regarding conflicts of interest, Participant Two observes, “Implementing the same conflict of interest prevention measures as the United States is not feasible in Iran. Here, certain connections inevitably exist or have existed, leading to conflicts of interest”.

Participant One discusses the independence of accreditation evaluators’ votes and considerations during visits: “In both educational and hospital accreditation, evaluation teams operate based on ministry guidelines. They consider various factors, often acknowledging limitations such as insufficient faculty facilities or low student-to-professor ratios.” They add, “Healthcare professionals may disregard patient rights because accreditation is internally managed. We recognize issues, but evaluators still assign scores. External evaluators tend to make more accurate assessments”.

Participant Seven points out discrepancies in the accreditation process: “When a team reports poor conditions, yet the National Commission grants accreditation, it indicates a flawed system. Results don’t reflect reality, suggesting considerations beyond current circumstances influence decisions.”

Participant Six compares different systems: “Countries like Saudi Arabia have government accreditation systems similar to ours. However, they operate with more authority and fewer constraints. They’ve received proper training in these matters.”

Outcome of accreditation

This category includes subcategories: “Performance quality of educational institutions,” “Graduate performance,” and “Involvement of various stakeholders in accreditation.”

Regarding educational institution performance quality, Participant Eleven states, “Realistic assessments require practical standards—minimum requirements for educational processes. Current minimums are inadequate given the capacity that existed before universal acceptance. The sudden increase in institutions has undermined accreditation. Previous evaluations noted low academic staff numbers and insufficient professors, but capacities have increased while shortages persist. Quality has clearly declined, and accreditation should reflect this. Do current accreditation results accurately portray this situation?”

Participant One suggests a gradual approach: “We must progress incrementally. If accreditation bodies are held accountable for institutional output, it significantly enhances quality by eliminating unnecessary considerations”.

Regarding stakeholder participation, the same participant notes, “Accreditation involves representatives from various groups: ministries of science, legal professionals, insurance companies, and even the general public. Government representatives may or may not be present, but they don’t impose specific conditions on colleges, universities, or hospitals.”

Addressing graduate performance, they continue: “Our general medicine graduates aren’t equivalent to American counterparts. They undergo additional training when working or studying in America. Their performance is evaluated… Once you accredit an institution and assess its graduates’ results, you should examine how graduates from different universities perform. Performance review results should align with the accreditation results of the institutions that trained them. Poor societal performance should hold the accrediting institution or program accountable.”

Areas for improvement in accreditation implementation

This theme comprises two categories: “Improving the structure” and “Improving the implementation process.”

Fig. 2

Areas for improvement in accreditation implementation

Improving the structure

Subcategories include “The government structure of the accreditation system,” “Insularity of the country’s accreditations,” and “Political considerations.” In Iran, accreditation has a governmental structure overseen by the Ministry of Health, Treatment and Medical Education. Educational accreditation occurs in program and institutional forms, also hospital accreditation in education and treatment (service provision) is conducted periodically.

Participant Seven critiques the governmental structure: “sameness of both education trustees and approval trustees within the government, results may lack reliability. “Participant Six offers a comparison: “Countries like Saudi Arabia have government accreditation systems similar to ours. However, they operate with more authority and fewer constraints. They’ve brought in foreign experts to teach these concepts correctly, resulting in proper, principled training. Their system maintains independence while progressing”.

Participant One addresses the insularity of Iranian accreditations: “Medical facility accreditation encompasses human resources and all hospital medical issues. Educational accreditation examines fields separately. We should move away from this insular approach, as doing so would create synergy”.

Participant Six highlights systemic issues: “Defects exist in all accreditation elements: indicators, processes, determinations, execution methods, conclusions, analyses, and decision-making. Flaws permeate all dimensions, worsening due to current national problems. Universities and programs know that even if processes are flawed, they won’t lose credibility. They receive conditional accreditation and simply provide documentation claiming resolved deficiencies or improved processes”.

Participant Three adds, “Everyone tries to present a better image than reality. They manipulate the process, even attempting to influence accreditation teams or pressure committees. It may sound pessimistic, but that’s my opinion.”

Improving the implementation process

Subcategories include “Increasing the reliability of evaluators’ opinions,” “Paying attention to the characteristics and goals of Iran’s accreditation system,” and “Compensation for the effort of people involved in the implementation of accreditation.”

Participant Three addresses evaluator reliability: “Uncertainty in accreditation results partly stems from non-standardized evaluator opinions. In developed countries, evaluators assessing institutions or programs reach consistent conclusions, indicating thorough evaluator training”.

Participant Twelve discusses wages: “when it is not properly compensated the effort whom implementing accreditation they view it as mandatory extra work, which is accurate since they’re not paid for it. It’s an additional burden on top of their routine tasks. Lack of compensation leads to dissatisfaction and diminished motivation”.

“Participant Four concurs: “Inadequate support and compensation for services reduce external motivations. Internal motivations have also decreased, resulting in weaker evaluation teams than expected”.

Participant Eight reflects on the accreditation system’s characteristics and goals: “Many accreditation concepts are now accepted and understood. Our system’s strength lies in its decade-long continuity, unlike other temporary projects. However, continuity alone is insufficient. Results should undergo annual reviews, with continuous assessment and process modifications to enhance performance”.

Participant Six concludes by addressing systemic challenges: “The educational system faces numerous intervening factors. Inappropriate student selection processes lead to unmotivated, unqualified students, limiting professors’ effectiveness. The increasing number of such students, coupled with inadequate infrastructure, poses significant challenges for educational institutions. The lack of facilities for low-performing students, combined with the migration of more capable and motivated individuals, inevitably decreases quality. The educational system loses capable individuals. In this context, what impact can the accreditation system have on quality? Even with a well-functioning accreditation system, its executive arm remains compromised”.

Discussion

The current research endeavored to elucidate the challenges and strengths inherent in the implementation of the accreditation process for educational institutions and programs, as perceived by experts in the field of educational accreditation. By scrutinizing these challenges and strengths through the lens of those directly involved in educational accreditation, this study not only delineates the current state of accreditation system in Iran, but also serves as a potential roadmap for its future evolution. Furthermore, the comparative analysis of the strengths, weaknesses, and challenges of accreditation implementation with analogous cases in other studies provides valuable insights for refining the accreditation process.

Globally, the responsibility for accreditation often lies partially outside the governmental sphere. In countries such as the United States, the non-governmental sector plays a pivotal role in implementing the accreditation of educational institutions and programs. In the United States, privately managed accrediting institutions gain recognition from two key entities: the U.S. Department of Education and the Council for Higher Education Accreditation (CHEA), a non-governmental agency. The United Kingdom adopts a different approach, where accreditation falls under the purview of the private sector, mirroring the structure of higher education. The Higher Education Quality Assurance Agency, governed by the heads of the Royal Colleges of England, collaborates with the Accreditation Council of England, a charitable and non-profit organization, to oversee the accreditation of institutions and colleges. In contrast, countries such as Iran and South Korea entrust the implementation of accreditation to the governmental sector. Some nations, like Malaysia, have adopted a semi-governmental structural approach to accreditation [9].

The government’s role in accreditation and the management of conflicts of interest within the accreditation structure elicited strong opinions from participants. An overwhelming majority of the participants (12 out of 13) contended that the governmental structure of accreditation in Iran precludes effective management of conflicts of interest. Drawing parallels with pioneer countries in accreditation, participants advocated for the exclusion of political considerations from the visitation process and announcement of accreditation results, aligning with the overarching goal of quality improvement. To achieve this objective, they proposed transferring accreditation responsibilities to the non-governmental sector. These findings resonate with Gharibi et al.‘s study from Iran, which concluded that the lack of separation between accreditation and licensing bodies results in a fundamentally flawed accreditation structure [12].

A qualitative study by Jafari Pouyan and colleagues from Iran delved into the pivotal role of accreditation evaluators in enhancing the credibility of accreditation results. Their findings, categorized into six distinct domains (personality, experience, knowledge, attitude, skill and extra-role behavior of evaluators) led to the conclusion that an optimal combination of these identified criteria is indispensable for an accreditation assessor [13]. These findings corroborate the results of the current research, particularly regarding the necessity of regular, comprehensive training for evaluators to foster unity while acknowledging individual differences and characteristics.

A recurring theme emphasized by participants was the imperative for a common and uniform understanding of standards, coupled with the continuous revision of developed standards. This finding resonates with the research conducted by Agha Bagheri and colleagues from Iran, which underscored the necessity of developing an official guide to resolve conflicts and establish a consistent framework for interpreting standards [14].

In the realm of applying executive guidelines for the accreditation system, participants underscored the critical importance of correctly interpreting and adhering to these guidelines to ensure confidence and uniformity in accreditation outcomes. This perspective aligns closely with the findings of Claudio’s 2023 research from the Philippines. In his comprehensive study, Claudio sought to identify the obstacles impeding the achievement of accreditation for educational institutions. His findings revealed a constellation of administrative support issues that pose significant barriers to the proper implementation of accreditation, including: the absence of an internal evaluation board or quality assurance office, a lack of operational structure to ensure proper management of accreditation tasks, the absence of a written policy governing documentation and filing for accreditation, suboptimal implementation of guidelines, irregular monitoring and evaluation of the accreditation process, limited academic and administrative projects and programs, and non-cooperation of personnel in providing requisite documents [4].

The issue of compensation for those involved in implementing accreditation emerged as a significant concern. Experts posited that inadequate compensation for the efforts expended in accreditation processes could lead to diminished motivation, potentially compromising the integrity of future accreditation cycles. This perspective aligns with the findings of Yarmohammadian et al., which concluded that the perception of accreditation among employees, given its complexity and time-intensive nature, contributed to increased workload and stress. The authors advocated for heightened attention from planners to address this issue and facilitate proper accreditation implementation [15].

Regarding the distinctive features and objectives of Iran’s accreditation system, participants highlighted several critical factors that potentially undermine the credibility and validity of accreditation results in guaranteeing educational quality. These factors include the relative novelty of accreditation, the dual role of education and accreditation trustees, the lack of decisiveness coupled with the consideration of political and social factors in accreditation outcomes, and the application of uniform evaluation standards across diverse institutions and programs. These findings echo those of Yarmohamedian’s study, which identified the use of a monolithic set of standards to evaluate organizations in disparate environments as a significant impediment to the accuracy of accreditation results [15].

Dividing the hospital accreditation in Iran into two types: educational and non-educational accreditation emerged as a contentious issue. Participants argued that this bifurcation does not positively impact service quality, whether educational or therapeutic. The current insular approach (separating educational and therapeutic accreditation of hospitals) stemming from the unified custodianship of medical education and service provision, was seen as fostering an incomplete view of academic medical science institutions. Consequently, the prevailing accreditations fail to adequately reflect the primary outcome of the health education system: the provision of public health.

The issue of stakeholder participation in accreditation emerged as a critical concern. While participants emphasized the necessity of stakeholder involvement, they perceived a significant gap in the consideration of stakeholder opinions and participation across various domains, including decision-making, development of accreditation structure and processes, standard-setting, and legal decisions pertaining to accreditation.

Gharibi’s research further illuminated deficiencies related to the policies, values, and culture governing Iran’s accreditation system. These included inadequate stakeholder participation in the accreditation process and the persistence of accreditation programs despite governmental changes, aligning with the characteristics, goals, political considerations, and structural aspects of Iran’s accreditation system [16].

Opinions diverged regarding the impact of accreditation on the performance quality of educational institutions. Some participants posited an enhancement in educational service quality at both institutional and program levels following the implementation of accreditation standards. Others, however, were more skeptical, citing the consideration of multifaceted factors (social, political, cultural, and economic) by evaluators and accreditation decision-makers as potentially diluting the reliability and validity of educational accreditation’s cumulative effects.

Bishop’s research provided a critical perspective, concluding that traditional accreditation, with its retrospective focus, exerts minimal influence on change and quality improvement. Moreover, Bishop noted that continuous development has neither been the primary objective of accreditation nor has it effectively promoted the sharing of best practices [17].

The current research findings regarding accreditation’s impact on institutional performance quality align with Ulker’s 2018 study. Ulker and colleagues observed that accreditation yielded more substantial process improvements in institutions with over 41 years of history compared to those aged 1–20 years. Furthermore, they found that initial accreditation contributed more significantly to process enhancement than subsequent accreditations. Notably, the study revealed that accreditation placed the greatest emphasis on learning outcomes, with the least focus on graduation rates [18]. Participants in the present study offered nuanced perspectives on the current state of accreditation. They noted that while accreditation sometimes yields tangible results under the current tenure system, no institution or program faces the loss of accreditation based solely on evaluation outcomes. They observed that during the initial phases of accreditation implementation, when familiarity with the judgment process was limited, institutions demonstrated greater diligence in meeting standards.

Berry and Saunders’ research provided a complementary viewpoint, concluding that accreditation protocols effectively identify areas of weakness requiring improvement. Their study suggested that this process has the potential to positively influence learner growth [19], a finding that resonates with some of the opinions expressed by participants in the current study.

The implementation of new programs invariably entails an increased workload, with the creation of documentation and the execution of evaluation and audit activities being particularly time-intensive. Consequently, it is imperative to consider factors that enhance employee motivation and participation while ensuring an equitable distribution of responsibilities. The approach adopted by senior organizational managers in implementing and managing accreditation directly influences the realization of changes and quality improvement [20]. The accreditation process inevitably augments employee workload, necessitating a fair and equitable distribution of tasks among university staff [21]. This theme recurred frequently in participant statements. Corroborating these findings, Mahmoudian et al.‘s research highlighted several factors crucial to successful accreditation implementation, including effective management and guidance by supervisors, managerial attention to employee encouragement, provision of rewards, and clear communication of objectives [22].

Conclusions

This research offers a nuanced portrayal of the current state of educational accreditation through the expert lens of those deeply involved in the field. While accreditation has contributed to improvements in educational quality, systemic issues continue to hinder its full potential. Issues such as the considerations that evaluators make during visits, the lack of complete independence of evaluators, and the lack of participation of all stakeholders in the development of standards. These cases are closely related to the fact that the same entity oversees both the higher education system and the accreditation system. The separation of hospital accreditation into two aspects, therapeutic and educational, prevents creating a general view of its processes.

Suggestions for improving accreditation in Iran

• Establishing a non-governmental accreditation body to ensure impartiality and increase public trust.

• Comprehensive and regular training of accreditation assessors to increase the reliability of their opinions.

• More attention to conflicts of interest in accreditation assessors.

• Increasing stakeholder participation in developing accreditation standards.

• Integrating educational and medical accreditation of hospitals to create a more comprehensive approach to organizational evaluation.

• Developing a meta-accreditation system to ensure the accuracy and precision of the educational accreditation system in Iran.

Limitation

As with all qualitative research, this study has inherent limitations, including challenges with generalizing the findings to broader populations or contexts beyond the specific sample. Additionally, the study’s results may not fully apply to settings with differing educational systems or cultural structures, particularly those outside the context of Iran. Further research with larger, more diverse samples and comparative analyses across countries could provide broader insights.