title: Impact of the Iranian hospital grading system on hospitals' adherence to audited standards: an examination of possible mechanisms.
abstract: BACKGROUND
  All Iranian hospitals have been subject to a grading system which determines the payments they can charge. We examined all possible pathways through which the grading system could influence hospitals' adherence to audited standards.
  
  
  METHODS
  Using a mixed methods study we examined five stakeholder groups: hospital staff, patients, general practitioners, health insurance organisations and surveyor organisations. Data were collected via semi-structured interviews, a questionnaire survey, observation and documentary analysis.
  
  
  RESULTS
  Patients and general practitioners were generally unaware of the hospital grading. Hospital staff and insurance organisations were informed, but this was not found to influence the hospital staff's choice of where to work nor the insurance organisations contracting behaviour. The grading system was criticised for the performance standards' validity and the validity of hospitals' awarded results. Hospitals responded to financial and reputational incentives for achieving better grades, although gaming and misrepresentation was also reported.
  
  
  CONCLUSIONS
  Pay-for-performance was the main influential factor in shaping hospitals' adherence to audit standards. Other potential mechanisms for influencing hospital behaviour, the selection mechanism and intrinsic motives, were not found to be sufficient to affect hospital behaviour.
authors.affiliation: Health Management and Economics Research Centre, Iran University of Medical Sciences, Tehran, Iran; School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran. Electronic address: a-aryankhesal@tums.ac.ir.
authors.forename: Aidin
authors.initials: A
authors.lastname: Aryankhesal
authors.affiliation: Department of Health Sciences, University of York, York, UK.
authors.forename: Trevor A
authors.initials: TA
authors.lastname: Sheldon
authors.affiliation: Health Services Management Centre, University of Birmingham, Birmingham, UK.
authors.forename: Russell
authors.initials: R
authors.lastname: Mannion
mesh_terms: D000068:Accreditation / Q000379:methods / Q000592:standards; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007492:Iran; D008485:Medical Audit / Q000592:standards; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care / Q000592:standards; D012052:Reimbursement, Incentive / Q000592:standards
keywords: Accreditation; Hospital grading; Incentive mechanisms; Iran; Pay for performance; Performance measurement; Reimbursement