Integration and adequacy assessment of health, safety, and environment indicators in the last national hospital accreditation program of Iran for sustainable healthcare development

Hospital accreditation programs are vital for maintaining the quality, safety, and sustainability of healthcare services. Yet health, safety, and environment (HSE) factors are often embedded in other standards rather than treated as distinct elements, limiting their effectiveness. This study examined how well HSE determinants are integrated and represented in the latest national hospital accreditation program (NHAP) in Iran. Based on a qualitative research approach, accreditation manual was analysed through expert consultations and focus group discussions (FGD) with HSE specialists and hospital managers. Relevant indicators were identified, categorised, and evaluated based on adequacy and implementation level. Of 505 indicators, 121 were related to HSE—mainly health (72), followed by safety (48) and environment (1), demonstrating health sector dominance. Expert feedback from our panel led to notable revisions, including 28 integrated, 13 updated, and 10 newly added standards. Over half of all indicators (52.9%) were classified as basic (minimum obligatory requirements), reflecting core HSE expectations. The revised framework improves the coherence and practicality of accreditation standards. While health remains the strongest component, further attention to environmental sustainability and staff well-being is needed to build safer, healthier, and more accountable hospitals. Strengthening environmental and occupational health indicators also directly contributes to the long-term sustainability and resilience of healthcare institutions.