Defining Emergency Department Necessary Policies Based on Clinical Governance Accreditation Scores

<strong>Introduction:</strong> The role of accreditation scheme in quality improvement of emergency departments (ED) has not been thoroughly evaluated in studies. Therefore, this study was designed to appraise the effects of policies defined based on clinical governance accreditation scores, on improvement of the procedures in ED. <strong>Methods:</strong> The present cohort study was carried out in the ED of Alzahra University Hospital, Isfahan, Iran in 2012-2013. In 2012 the deficiencies in ED of this hospital was determined based on clinical governance indicators. Then the deficiencies were classified based on their importance and changes were made in the ED. Finally, the effects of the changes were evaluated in August 2013. <strong>Results:</strong> The evaluation made in 2012 showed that 23 clinical and non-clinical procedures were carried out with deficiencies. Over the mentioned period, 6 (26.1%) procedures were not done at all, while 17 (73.9%) were done without a policy and irregularly. The overall score for clinical and non-clinical procedures in the ED before carrying out the accreditation scheme was 43 / 230 (18.7% of the maximum possible score). The score was raised to 222 equal to 96.5% of the maximum possible score after carrying out the scheme. This increase was statistically significant (p &lt; 0.001). <strong>Conclusion:</strong> The findings of the present study showed that defining policies for improving the procedures carried out in ED based on accreditation scheme leads to improvement of medical services in ED