1. ISQUA-1233
Senior Managers’ Perspectives on CBAHI Accreditation: A Qualitative Study
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
Accreditation is one of the most important tools for quality improvement in healthcare organisations. It is a means by which health services are assessed externally to determine whether they comply with international standards. Saudi Arabia has only recently implemented accreditation processes to improve healthcare programs. In 2005, the Central Board for Accreditation of Healthcare Institutions (CBAHI) was established following the recommendations of the Council of Health Services (Saudi Arabia). The CBAHI was formed to develop and implement quality standards in all health organisations in Saudi Arabia to improve health services. The impact of accreditation on public hospitals in Saudi Arabia is an important issue for those demanding improvements in the quality of care delivered in this system.
Objective
The aim of this study is to explore the perspectives of senior managers about CBAHI accreditation.
Thematic Category
Thematic Sub-Category
Example
Reasons for Seeking Accreditation
Political Pressure
We did not choose to join the CBAHI accreditation; [the impetus] came from the MOH and it was compulsory, to be honest with you. If it was our choice, we would not have joined it, as it is not an easy thing. (M.C.)
Social Pressure
 Global Pressure
Challenges to Joining the CBAHI
Staff Resistance
When you put [people] in line, they may not stand, they want to go here and there, so if you try to lead them in one line, they resist a little bit, so this is resistance to change. Nobody likes change, and change will take time, and some people naturally are not the same – some people want to change, some people need to be forced to change, and some people will never change. (respondent 4.)
Lack of Staff Involvement
Limited Knowledge of Quality and Accreditation
Language Barriers
Shortage of Manpower
Benefits of Joining the CBAHI
Cultural change with a shift to client-centered, team-based quality services
We have a mission and vision and these came from the CBAHI process. We did not have a mission and vision until the CBAHI told us that the hospital should have [this]. (Q.A.)
Implementation of mission/vision statements
Enhanced communication
Improved reporting of medical errors
Improved medical record keeping
Criticism of CBAHI
Increased workload
Surveyors assessed our hospital in a few days. CBAHI seems more like a routine check, rather than an evaluation and continuous improvement program. (M.C.)
Excessive paperwork
Focus on structure over clinical practice
Cross-sectional nature of the CBAHI
Suggestions to improve CBAHI
Community involvement
We need to have more communication with the public in the region. I think there is a barrier between people and the hospital. We are trying to involve people in programs [such as] the hand hygiene program. I think people in the community should be more involved in the hospital, they should know what is going on. (Q.A.)
Continuous Education
Leadership Support
Culture of quality
Methods
Qualitative study
Semi-structured interview with senior managers
12 interviews
20-40 minutes
Data collection
Thematic analysis
The fact that we did not find stronger evidence for an added value of the accreditation program may be partially explained by CBAHI surveys present a problem, as they do not monitor the continuous delivery of health care. Surveys permit merely snapshots in time, thus compliance with standards may deteriorate because of the long intervals between surveys. Therefore, activities that address accreditation requirements, or clinical performance, may be peak and trough in tune with the accreditation survey (Greenfield, et al., 2012a).
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Another reasons may also be partially explained by CBAHI accreditation being in the early stages of adoption, and the impact of accreditation appears to be in its infancy. Therefore, the effect of accreditation may not be realised directly after implementation. Another reason might be that CBAHI standards are not designed specifically to reflect outcomes and may not measure those practices and procedures that are most important for ensuring safe patient care. Alkhenizan and Shaw (2010) reported the lack of measurable indicators in CBAHI standards. The motivation of staff to participate in the accreditation process will be difficult unless accreditation is perceived as a benefit at a clinical level. Accreditation programs should consider an approach that evaluates not only structure and process but also outcomes, which is the ultimate objective of quality improvement practice (El-Jardali 2007). CBAHI accreditation might be more of an inspection than a continuous quality improvement process. Making accreditation mandatory, particularly for new programs such as CBAHI, is not recommended, as it shifts the objective solely to gaining accreditation instead of improving quality of care (Pomey et al. 2005), and puts the hospitals under pressure.
This thesis illustrated the need to sustain improvements over the accreditation cycle; this means meeting the immediate accreditation standards, as well as establishing a basis for ongoing quality improvement into the future.
The characteristics of sustained improvement over the accreditation cycle
Unannounced Survey
Modern Accreditation (Structures, Processes and Outcomes)
Continuous Quality Improvement
Voluntary Accreditation
PDCA
Leadership Support
Quality Culture
Continuous Training
Physician Involvement
Results
The results of thematic analysis of the semi-structured interviews revealed a mixed picture. Although the interviewees acknowledged the benefits of accreditation, such as improved communication, patient satisfaction, reporting systems, workplace culture, and the implementation of an organisational mission and vision, they also criticized accreditation. Accreditation was criticized for being too focused on paper work, and failing to involve physicians. Other criticisms included manpower shortages during the process, a lack of staff involvement, an increased workload and an emphasis on structure over clinical practice; accreditation was also viewed as cross-sectional rather than focused on improvements over time. Senior managers suggested that community involvement, leadership support, training and reforming the workplace culture were important factors in improving quality of care and accreditation.
Discussion and Conclusion
The results of this study demonstrate that although some improvements in the procedures have been recognised, CBAHI accreditation was not associated with better outcomes. These results are consistent with those of Merkow and colleagues (2014), who found that accredited centres performed well on most process measures but not on outcome measures.
As literature has indicated that a proper process of care may increase the likelihood of good outcomes, it is not clear whether the improvements in the processes can be attributed to the accreditation program. Being accredited does not ensure this much desired result. In short, the true value associated with accreditation will only be realized when it can be conclusively shown that it achieves tangible improvements in quality of care (El-Jardali 2007).
References
Greenfield D, et al,. 2012a. The role and impact of accreditation on the healthcare revolution.