1. ISQUA-10
The Impact of Accreditation on Quality of Care: A Cross Sectional Study in Saudi Arabia
Mohammed Almasabi (1,2), Dr Hui Yang (1) and Professor Shane Thomas (1) 1- School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
2- Ministry of Health, Saudi Arabia
Introduction
Health service organisations are under pressure to improve the quality of care (Figueras et al. 2005; Shortell et al. 1995). In response to this pressure, health service organisations in countries worldwide consider accreditation as the key approach to achieve this goal (Sax and Marx, 2013).
The goal of developing accreditation is to determine whether a health-care organisation has met the quality standards set at the national level (Pomey et al. 2005). Accreditation is based on the premise that adherence to evidence-based standards will produce higher-quality health-care services in an increasingly safe environment. Accreditation can increase public awareness that a health care organisation has met national quality standards.
However, there is a lack of empirical evidence to demonstrate whether hospital accreditation is effective, internationally and in Arab countries in particular. This creates a legitimacy problem for policy-makers and hospital management. Many countries are embarking on hospital accreditation without any evidence that it is the best use of resources for improving quality. While the value of accreditation is indeterminate, evidence does not show conclusively that there are no benefits to accreditation or that resources are being wasted. The literature prompts a rethink of how accreditation contributes to clinical and organisational performance. Consequently, without an empirically grounded evidence base for accreditation, the debate about the effect of accreditation—positive or negative—will remain anecdotal, influenced by political ideology and driven by bias.
Objective
The impact of accreditation on public hospitals in Saudi Arabia is an important issue for those demanding improvement in quality of care. This study aimed to examine the impact of accreditation on quality of care.
Variables
Mean SD
Cronbach’s Alpha
Leadership
3.90
.755
0.880
Strategic planning
3.79
.773
0.855
Patient focus
3.86
.726
0.835
Measurement and analysis
.677
0.837
Training
3.69
.818
0.892
Operational focus
3.82
.759
0.871
Professional participation
2.93
1.036
0.866
Staff involvement
3.87
.722
0.918
Benefits of accreditation
3.98
.672
0.942
Quality results
.728
0.891
Accreditation results
3.60
.842
0.865
Model
Sig. B
Std. error
Benefits of accreditation
.686
.041
0.000
Measurement and analysis
.244
.047
Professional participation
.098
.029
0.001
Leadership
.094
.045
0.038
aDependent variable: accreditation results
Discussion Conclusion
The Pearson correlation measurement and multiple regression analysis showed that there are positive relationships between quality process sub-scales and quality results and quality process sub-scales and accreditation results.
Quality outcome sub-scales are measured by quality results and accreditation results. Regression findings revealed that operational focus, benefits of accreditation, patient focus, staff involvement in the accreditation process, measurement analysis and professional participation were associated with better scores in terms of quality results. The results also revealed that the benefits of accreditation, measurement and analysis, professional participation and leadership were associated with better scores in relation to accreditation results. Some of the findings are consistent with those of previous studies, and some differ from those presented in previous research. For example, a study carried out by Yildiz and Kaya (2014) found that the benefits of accreditation was the most predictable quality outcome variable. Another study conducted in Lebanon by El-Jardali et al. (2014) found strategic planning, patient focus, and staff involvement were the most predictable variables in terms of quality results. An earlier study, also by El-Jardali et al. (2008), found leadership, measurement and analysis, operational focus and staff involvement in the accreditation process were associated with better quality results.
In regard to the predictability of quality results, the results of regression analysis rank operational focus first, benefits of accreditation second and patient focus third. In regard to the predictability of accreditation results, benefits of accreditation is ranked first, measurement and analysis is ranked second, and professional participation is ranked third. This research indicated that focusing on operational focus, benefits of accreditation, patient focus, measurement analysis, and professional participation, will lead to an improvement in quality outcomes. However, this predictive ranking differs from the results of El-Jardali et al. (2008), who reported that leadership is the most important driver of quality outcomes.
A prominent response to the open-ended questions was that the accreditation process focused too much on paperwork. An Iranian study by Ravaghi et al. (2014) supports this result; they found that accreditation increased paperwork. The literature acknowledges that accreditation is demanding of participants’ time, which may present a challenge to, and result in conflict with, the daily demands of individuals’ work roles (Weiner, Alexander et al., 2006).
The results of this research suggested that respondents did not feel they had received sufficient and continuous training to fulfill their accreditation role. These findings clearly echo those of others, particularly Rad (2006), who established in his research, undertaken across a number of hospitals, that a lack of training represented a significant barrier to the implementation of accreditation.
Some respondents mentioned that monitoring after accreditation was not implemented. The accreditation process tends to be more reactive than forward-looking. It only takes snapshots of performance and identifies point-in-time deficiencies, as it is a periodic, rather than continuous, assessment (Lewis, 2007). Accreditation surveys present a problem, as they do not monitor the continuous delivery of healthcare. Since surveys permit snapshots in time, compliance with standards may deteriorate because of the long periods between surveys; in some cases, up to three years can pass between surveys (Scrivens, 1995b).
Correlations
Quality Results
Accreditation Results
Leadership
.540**
.402**
Strategic planning
.515**
.361**
Patient focus
.595**
.417**
Measurement and analysis
.591**
.432**
Training
.559**
.413**
Operational focus
.645**
.415**
Professional participation
.421**
.347**
Staff involvement
.574**
Benefits of accreditation
.632**
.547**
Quality results
Accreditation results
**Correlation is significant at the 0.01 level (2-tailed).
Methods
Cross-sectional study
Survey with health practitioners
A panel reviewed the survey
Pilot study
Data collection
68% response rate
Data Analysis
Sig. B
Std. Error
Operational focus
.618
.028
.000
Benefits of accreditation
.423
.036
Patient focus
.221
.035
Staff involvement
.190
.033
Measurement and analysis
.105
.041
.012
Professional participation
.043
.021
.039
aDependent variable: quality results
Open-ended question results
Five main themes emerged from the open-ended question:
Accreditation should be more focused on patients rather than documentation
Focus on paper work
After accreditation, education and training were totally ignored; education should continue and would result in better outcomes and safety
Lack of training
After accreditation, I felt everything went back to before accreditation, with only small changes in terms of paperwork
No monitoring after passing
Accredited hospitals need more staff to maintain standards, but here even our basic needs have not been met and therefore we cannot provide safety
Manpower shortages
Before accreditation, the hospital promised that if the hospital became accredited, the hours of duty would be decreased and the salary would be increased as well, but none of these things happened so there was no benefit for us from accreditation
Unfulfilled promises
Results
In term of mean scores, benefits of accreditation had the highest mean score and professional participation had the lowest mean score
We found a statistically significant positive correlation between dependent and independent variables ranging from (professional participation ) to (operation focus) .
Quality results increased by 0.62 for every unit increase in operation focus, by 0.42 for every unit increase in benefits of accreditation, by 0.22 for every unit increase in patient focus, by 0.19 for every unit increase in staff involvement, by 0.10 for every unit increase in measurement and analysis, by for every unit increase in professional participation.
Accreditation results increased by 0.69 for every unit increase in benefits of accreditation and by 0.24 for every unit increase in measurement and analysis.
References
El-Jardali F, Jamal D, Dimassi H, Ammar W, Tchaghchaghian V The impact of hospital accreditation on quality of care: Perception of Lebanese nurses. International Journal for Quality in Health Care, 20:
Hinchcliff R, Greenfield D, Moldovan M, et al. 2012b. Narrative synthesis of health service accreditation literature. BMJ Quality & Safety, 21:
Pomey M, Contandriopoulos AP, François P, Bertrand D Accreditation: a tool for organizational change in hospitals? International Journal of Health Care Quality Assurance, 17:
Shortell SM, O'Brien JL, Carman JM, et al Assessing the impact of continuous quality improvement/total quality management: Concept versus implementation. Health Services Research, 30: 377.