THE INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT

Int J Health Plann Mgmt 2016

Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/hpm.2373

The impact of Saudi hospital accreditation on

quality of care: a mixed methods study
Mohammed Almasabi1* and Shane Thomas2
1
Ministry of Health, Saudi Arabia
2
School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash
University, Melbourne, Australia

SUMMARY
In 2005, the Central Board for Accreditation of Healthcare Institutions (CBAHI) was launched
in Saudi Arabia in order to improve the quality of care. By 2010, the first hospital was
accredited by CBAHI, followed by many hospitals in following years. The aim of this study
is to examine the impact of CBAHI on quality of care. In this study we used a mixed methods
approach involving surveys, documentary analyses and semi-structure interviews. Surveys
data were collected from 669 staff. Documentary analyses included mortality, infection and
length of stay. The semi-structure interview data were gathered from 12 senior managers. Data
were collected from three accredited public hospitals. Although some improvements in proce-
dure were recognised, CBAHI does not monitor the continuity of health care delivery and had
no effect on quality outcomes in our analysis. This study illustrates a need to sustain improve-
ments over time in the accreditation cycle. Copyright © 2016 John Wiley & Sons, Ltd.

KEY WORDS: accreditation; quality of care; Saudi Arabia

INTRODUCTION

Health service organisations are under pressure to improve the quality of care
(Shortell et al. 1995; Figueras et al. 2005). In response to this pressure, health ser-
vice organisations in countries worldwide consider accreditation as the key approach
to achieve this goal (Sax and Marx, 2013).
The accreditation process is an essential part of quality health-care systems in
more than 70 countries (Greenfield and Braithwaite 2009). Notably the largest
recognised accreditation body in the world is the International Society for Quality
in Health Care. 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

*Correspondence to: Mohammed Almasabi, Ministry of Health, Saudi Arabia. E-mail: malmasabi@gmail.
com

Copyright © 2016 John Wiley & Sons, Ltd.

2 M. ALMASABI AND S. THOMAS

increasingly safe environment. Accreditation can increase public awareness that a

health care organisation has met national quality standards.
Accreditation standards generally fit into three categories: structure, process and
outcome. There are quality improvement benefits for each of these categories, but
the standards that deal with outcome or performance issues are generally considered
to be the most important to promote quality improvement (Hinchcliff et al. 2012b).
In developing countries, governments use accreditation to regulate and guarantee
quality of care. Accreditation has been established in relatively few developing
countries. However, there is growing interest in its implementation, and accredita-
tion is expected to provide staff with incentives to change their practices when
needed so that health-care outcomes are enhanced (El-Jardali et al. 2008).
In Saudi Arabia, the use of accreditation processes in health-care improvement
programmes has grown in importance in recent years. In 2000, The Makkah
Regional Quality Program (MRQP) was established to improve and enhance the
quality of health services being provided to the people of this region. High quality
organisations and strategies such as Joint Commission on Accreditation of
Healthcare Organizations and the Canadian Standard were studied before formulat-
ing the standards. In 2003, the first version for health standards was released and
applied throughout the region (Almasabi, 2013). In 2005, the Central Board for
Accreditation of Healthcare Institutions (CBAHI) was established, following the
recommendations of the Council of Health Services. The CBAHI was formed to
develop and implement quality standards in all health organisations in Saudi Arabia
to improve health services. Although the majority of accreditation programmes are
voluntary programme, CBAHI is mandatory. In 2011, the Council of Health
Services in Saudi Arabia declared that all public and private institutions must obtain
CBAHI’s accreditation.
However, while accreditation standards have been implemented more widely over
the past 40 years, and the probability of receiving safe and high-quality health care
has increased for patients worldwide (Pomey et al. 2010), it is not clear whether
accreditation programmes truly improve health organisations, services or clinical
care (Greenfield et al. 2012a).
Although Saudi Arabia is embarking on CBAHI accreditation to promote quality
improvement in health-care organisations, the evidence that it is the best use of
resources for improving quality processes and outcomes is lacking. This is because
research into its impact is at an early stage. This creates a legitimacy problem for
policymakers and hospital management. The absence of research on the CBAHI
accreditation programme contributes to a lack of understanding of the programme.
Without an empirically grounded evidence base for CBAHI, the varying positives
and negatives about its impact on quality of care will remain anecdotal, and can be
influenced by political ideology and driven by bias. Therefore, researching the effec-
tiveness of CBAHI is needed in order to determine whether it truly improves health-
care services and health outcomes and could help to maximise the potential of the
programme.
This study aims to develop an understanding of the impact of CBAHI on the qual-
ity of care in Saudi Arabia. It focuses on: (i) the perception of staff at CBAHI; (ii) the
relationship between quality indicators and CBAHI; and (iii) the perception of senior

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
 THE IMPACT OF SAUDI HOSPITAL ACCREDITATION ON QUALITY OF CARE 3
managers about CBAHI. This is the first study to our knowledge specifically explor-
ing the impact of CBAHI accreditation on quality of care.

METHODS

A mixed methods study design was utilised involving three studies. In recent years,
mixed methods research has emerged as the preferred paradigm for health-care
research (Zhang and Creswell, 2013), as this approach endeavours to provide data
that can be used to help decision makers develop health policy. Such an approach
responds to the pressures for measurable outcomes in health care (Doyle et al.
2009). There is growing acceptance that the mixed methods design provides an ap-
propriate methodology to address complex health problems. According to Hinchcliff
et al. (2012a), health service accreditation programme are complex interventions.
Our study used convergent design, frequently used in health research, in which data
are collected during a similar timeframe, an approach often used in health research
(Creswell 2009). Creswell (2009) argued that it may be unfeasible to collect
health-care data over an extended time period because health-care workers are busy
and have limited time. It can be more manageable to collect data at the same time,
rather than make multiple visits to hospitals for data collection. The triangulation
data-gathering method allows the study of complex phenomena, which might be
impossible if only one method were used (McMillan and Schumacher, 2014), and
it was particularly recommended in health accreditation research as it strengths
and promotes the generalisability and credibility of results by facilitating compara-
tive confirmation of findings (Hinchcliff, et al., 2012a).

Study 1: Survey of quality of care and accreditation

Study one used quantitative data associated with surveys aiming to examine the im-
pact of accreditation from respondents’ perspectives. Quantitative data can provide a
useful summative assessment of the value of health accreditation (Hinchcliff et al.
2012b). The present research used a survey adapted from those used in earlier studies
which examined quality of care and accreditation (Shortell et al. 1995; Pomey et al.
2004; El-Jardali et al. 2008).
The survey contained 56 items: 8 on demographic data. The other 48 items mea-
sured 11 dimensions associated with quality of care and accreditation. Each of the 12
dimensions included 3, 4, 5 or 8 survey items. Most of the survey’s items used a 5-
point Likert scale for agreement (5 = strongly agree, 4 = agree, 3 = neither, 2 = dis-
agree, 1 = strongly disagree) and frequency (5 = always, 4 = most of the time,
3 = sometimes, 2 = rarely, 1 = never). The survey was organised in four parts: demo-
graphics, quality of care, professional participation and accreditation. The dependent
variables were quality results (4 items) and accreditation results (3 items). The inde-
pendent variables were leadership (4 items), strategic planning (4 items), patient
focus (4 items), measurement and analysis (4 items), training (4 items), operation
focus (4 items), professional participation (4 items), staff involvement (5 items)
and benefits of accreditation (8 items). The survey went through a number of steps

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
4 M. ALMASABI AND S. THOMAS

to increase its validity and reliability. First, a panel of experts was consulted for their
comments and suggestions. Second, the survey was translated from English into
Arabic, then back-translated by another person. Third, a pilot study with 30 respon-
dents was conducted to ensure the soundness of wording, format and length. (This
pilot study was not included in the main study.) A number of minor changes were
made to the demographic portion and an-open ended question was added. Finally,
another group of experts were consulted about the finished product. Internal consis-
tency has been demonstrated using Cronbach’s alpha. Values of alpha are all >.8,
indicating that the reliability of the scales is good.

Study 2: Documentary analysis

Study two aimed to investigate the impact of accreditation on quality indicators.
Quality indicators measure the effects of an intervention—e.g. accreditation—on
patients (Scrivens 1997). CBAHI accreditation is a relatively new phenomenon in
Saudi Arabia. Therefore, there is a chance to compare quality indicators before
and after accreditation in order to measure and recognise the actual change effects
on individual cases triggered by the CBAHI. Hence, a pre-test/post-test design was
used (Polgar and Thomas 2013). Comparative before-and-after designs produce
strong evidence that any effects were because of the accreditation (Øvretveit and
Gustafson 2002). According to Hinchcliff and colleagues (2012b), there has been
limited use of clinical outcome measures to understand whether accreditation is
associated with improved health outcomes; they emphasise that the use of clinical
indicators would strengthen our understanding of the benefits of accreditation. We
purposely focused on three quality indicators namely mortality, infection and length
of stay (LOS), in anticipation of multiple effects from such a complex health system
intervention as is provided by the CBAHI.

Study 3: semi-structure interviews

Study three used qualitative method through semi-structure interviews. The aim of
this study was to capture senior managers’ voices towards accreditation. Qualitative
health-care accreditation research is important because it helps to highlight theoreti-
cal constructs in problematic areas that are difficult to measure objectively, by
uncovering factors which drive, or fail to drive, change in quantitative indicators
of performance (Hinchcliff et al. 2012b). In this study, the qualitative components
included semi-structured interviews with hospital directors, medical directors, qual-
ity directors and nursing directors. The interview tool covered the following topics:
reasons for seeking CBAHI, challenges to join CBAHI, benefits of CBAHI, criticism
of CBAHI and suggestion to improve CBAHI.

Setting
Because CBAHI accreditation is a mandatory programme for all hospitals in Saudi
Arabia, there is no possibility of comparing an accredited with a non-accredited
hospital to identify any changes resulting from the CBAHI. Thus, all of the hospitals
in this study were accredited. Public hospitals are the majority of hospitals in the

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
 THE IMPACT OF SAUDI HOSPITAL ACCREDITATION ON QUALITY OF CARE 5
Saudi Arabia, providing the majority (60%) of services in the country. The process
of CBAHI accreditation and the structure of the hospitals under the Ministry of
Health (MOH) are similar in all cities of the country. Therefore, all MOH hospitals
have similar characteristics for possible selection. To ensure geographic representa-
tion from different parts of the country, the study was carried out at three hospitals
from different regions across Saudi Arabia (hereafter referred to as Hospital A,
Hospital B and Hospital C)

Data collection
Data collection for this study was commenced after ethics approval was obtained
from the General Administration of Medical Research in the Saudi Arabian MOH.
We distributed a copy of the MOH approval letter, the invitation letter, an explanatory
statement, assurance of anonymity and confidentiality of the respondents and the
timeframe to all medical and administrative staff at three Saudi accredited public hos-
pitals. Participation was voluntary and return of completed surveys was treated as im-
plied consent. Data for the three studies were collected from September 2013 to
January 2014. A total of 669 surveys were returned, giving a response rate of
68.8%. Data of the three quality indicators (mortality, infection and LOS) were
collected from 2009 to 2013. We conducted semi-structured interviews with 12
senior managers, including hospital directors, medical directors, quality directors
and nursing directors recruited from all three hospitals. In particular, senior managers
were thought to hold the key to CBAHI accreditation. The interviews, lasting 20–
40 min, were conducted in the senior managers’ offices, were digitally tape recorded,
subsequently professionally transcribed and then translated into English (eight inter-
views were conducted in Arabic). Topics discussed included reasons and challenges
to join CBAHI, benefits and criticism of CBAHI and suggestions to improve it.

Data analysis
Study one data were analysed using SPSS v.20. Data analysis consisted of descrip-
tive statistics, including means with standard deviations and frequency distributions.
The relations between dependent variables and independent variables were evaluated
using Pearson correlations. To understand the association between dependent vari-
ables and independent variables, regression was calculated. For study two, odds ra-
tios (ORs) were used to measure the association between an exposure and an
outcome. Recently, ORs have become widely used in health reports (Bland and Alt-
man 2000), such as in the examination of accreditation effects (Dickison et al. 2006).
An OR represents the odds that an outcome will occur given a particular exposure,
compared with the odds of the outcome occurring in the absence of that exposure.
Therefore, ORs were used in this study to compare the relative odds of the outcomes
(mortality and infection) occurring given the exposure to the variable of interest
(accreditation). For LOS, an ANOVA test was used. Analysis of study three and
the open-ended question was performed using thematic analysis by the two authors.
The findings were first transcribed and coded to better manage the data. Next, find-
ings were broken into different concepts and ideas. The emerging concepts then were
organised into themes and subthemes.

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
6 M. ALMASABI AND S. THOMAS

RESULTS

Study 1 results
As seen in Table 1, most of the respondents were female (n = 526, 78.6%), half of
them below 30 years old (n = 332, 49.6%), and 554 (82.8%) were non-Saudi. A total
of 323 respondents (48.3%) had been working for 6–10 years, and more than half
(n = 368, 55%) had a bachelor’s degree. A total of 504 respondents (75.3%) were
nurses and 81 (12.1%) were physicians. The vast majority of the respondents
(n = 620, 92.7%) were at the employee level, and 512 (76.5%) were involved in the
accreditation process.
The mean scores computed for the scales are presented in Table 2. Benefits of ac-
creditation had the highest mean score (3.98), followed by leadership (3.90); staff in-
volvement (3.87); patient focus (3.86); operational focus (3.82); strategic planning,
measurement/analysis and quality results (all had a mean score of 3.79); training

Table 1. Demographic characteristics

Variable Categories Frequency Percent

Sex Male 143 21.4

Female 526 78.6
Total 669 100.0
Age Below 30 yr 332 49.6
31–40 yr 216 32.3
41–50 yr 75 11.2
More than 51 yr 46 6.9
Total 669 100.0
Nationality Saudi 115 17.2
Non-Saudi 554 82.8
Total 669 100.0
Experience 3–5 yr 286 42.8
6–10 yr 322 48.3
More than 11 yr 61 9
Total 669 100.0
Qualification Diploma 246 36.8
Bachelor’s degree 368 55.0
Higher degree 45 6.7
Other 10 1.5
Total 669 100.0
Profession Physician 81 12.1
Nurse 504 75.3
Health professional 49 7.3
Other 35 5.2
Total 669 100.0
Level Top manager 9 1.3
Middle manager 40 6.0
Employee 620 92.7
Total 669 100.0
Involvement in accreditation process Yes 512 76.5
No 157 23.5
Total 669 100.0

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
 THE IMPACT OF SAUDI HOSPITAL ACCREDITATION ON QUALITY OF CARE 7
Table 2. Means + standard deviations (SD) of the scales

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 3.79 .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 3.79 .728 0.891
Accreditation results 3.60 .842 0.865

(3.69) and accreditation result (3.60). Professional participation had the lowest mean
score (2.93).
In terms of leadership, 64.9% of staff (n = 434) agreed that the senior executives
consistently participated in activities to improve quality. In relation to strategic plan-
ning, 64.6% of staff (n = 432) agreed that each department and work group within the
hospital maintained specific goals to improve quality. In terms of patient focus,
61.1% (n = 409) of the staff agreed that the hospital did a good job of assessing pa-
tient needs and expectations.
For measurement and analysis, most staff (62.9%, n = 421) agreed that the hospital
continually tried to improve how it used data and information on quality. In relation
to training, the majority of the staff (64%, n = 428) agreed that hospital employees
were given training in how to identify and act on quality improvement opportunities.
In terms of operation focus, 63.4% of staff (n = 424) agreed that the hospital encour-
aged employees to keep records of quality measurement.
For quality results, 58.8% (n = 394) agreed that over the past few years, the hospital
had shown steady, measurable improvements in the quality of care provided to
patients.
The staff assessed to what extent they participated in hospital management. On the
one hand, 28.1% (n = 188) stated that sometimes they were involved in management
decisions concerning the workforce. On the other hand, 27.2% (n = 182) stated that
they were never involved in management decisions concerning the workforce. In ad-
dition, 35.4% (n = 237) claimed that their opinions were sometimes taken into con-
sideration when they were consulted in the decision-making process, whereas
22.1% (n = 148) stated that their opinions were never taken into consideration when
they were consulted in the decision-making process. Furthermore, 34.2% (n = 229)
of the staff and 36.5% (n = 244) of professionals rated their level of participation
in the hospital’s management at the ‘sometimes’ level.
In terms of staff involvement, more than half of the staff (63.1%, n = 422) agreed
that they learned of the recommendations made to their hospital since the last survey.
In relation to benefits of accreditation, around 62.2% (n = 416) agreed that accred-
itation enabled the hospital to better use its internal resources.

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
8 M. ALMASABI AND S. THOMAS

Finally, for accreditation result, 43.2% (n = 289) of staff agreed that the mortality
rate had decreased after gaining accreditation. Half of the staff (50.2%, n = 336)
agreed that the infection rate had declined after gaining accreditation. Moreover,
46% (n = 308) of the staff agreed that LOS had decreased after gaining accreditation.
As outcomes of accreditation, the dependent variables (quality results and accred-
itation results) were correlated with the independent variables, and we found that
there was a statistically significant positive correlation between dependent and inde-
pendent variables (Table 3). The correlation between operational focus and quality
results was ranked the highest (γ = .645, p < 0.000), and the correlation between pro-
fessional participation and quality results was ranked the lowest (γ = .421,
p < 0.000). The correlation between the benefits of accreditation and accreditation
results was ranked the highest (γ = .547, p < 0.000), and the correlation between pro-
fessional participation and accreditation results was ranked the lowest (γ = .347,
p < 0.000).
Table 4 presents the regression model where quality results were the dependent
variable. The model had R2 = 0.574, depicting a good fit. Model 1 contained one
predictor variable, operational focus; the variable explained 41% of the variation in
quality results. Benefits of accreditation explained an additional 10% of the variation
in quality results (for Model 2, adjusted R2 = 0.102). In models 3 and 4, patient focus
and staff involvement explained an additional 2.8% and 2.1%, of the variance in qual-
ity results, respectively (for models 3 and 4, R2 change = 0.28 and 0.21). In models 5
and 6, measurement and analysis and professional participation contributed an addi-
tional 0.4% and 0.3%, respectively (for models 5 and 6, R2 change = 0.04 and 0.03).
Table 5 presents the regression model where accreditation results were the depen-
dent variable. Stepwise regression is performed using nine predictors, and the model
had R2 = 0.343, depicting a good fit. The stepwise regression model 1 contained one
predictor variable, benefits of accreditation; the variable explained 30% of the
variation in accreditation results. Measurement and analysis explained an additional
2.7% of the variation in accreditation results (for model 2, R2 change = 0.027). In
models 3 and 4, professional participation and leadership explained an additional

Table 3. Pearson correlation between variables

Correlations
Quality results Accreditation results

1—Leadership .540** .402**

2—Strategic planning .515** .361**
3—Patient focus .595** .417**
4—Measurement and analysis .591** .432**
5—Training .559** .413**
6—Operational focus .645** .415**
7—Professional participation .421** .347**
8—Staff involvement .574** .417**
9—Benefits of accreditation .632** .547**
10—Quality results .540** .515**
11—Accreditation results .402** .361**
**Correlation is significant at the 0.01 level (two tailed).

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
 THE IMPACT OF SAUDI HOSPITAL ACCREDITATION ON QUALITY OF CARE 9
Table 4. Regression analysis results of quality processes on quality results

Coefficientsa
Unstandardised Standardised
Model coefficients coefficients
B Std. error Beta T R2 AR2 Sig.

Step 1
Operational focus .618 .028 .645*** 21.806 .416 .000
Step 2
Benefits of .423 .036 .390*** 11.866 .518 .102 .000
accreditation
Step 3
Patient focus .221 .035 .221*** 6.378 .546 .028 .000
Step 4
Staff involvement .190 .033 .188*** 5.669 .567 .021 .000
Step 5
Measurement and .105 .041 .098* 2.531 .571 .004 .012
analysis
Step 6
Professional .043 .021 .061* 2.069 .574 .003 .039
participation
a
Dependent variable: quality results
Note:
*p < 0.05,
**p < 0.01,
***p < 0.001.

1.2% and 0.4% of the variation in accreditation results, respectively (for models 3
and 4, R2 change = 0.012 and 0.04).

Open-ended question
Five main themes emerged from the open-ended question: paperwork, training, con-
tinuous monitoring, staff shortage and failure to fulfil promises. Majority of the re-
spondents to the open-ended question supported the notion of accreditation as
being focused on paperwork rather than on patient care. Although training is one
of the important aspects of quality of care, some respondents reported that there
was a lack of training and education after accreditation. Indeed, a respondent stated,
‘After accreditation, education and training were totally ignored; education should
continue and would result in better outcomes and safety.’
The third theme was that of the need for continued monitoring and focus on qual-
ity in the post-accreditation period, the majority of respondents emphasised that
there was no monitoring of quality after the accreditation process was finished. For
example, another respondent said, ‘After accreditation, I felt everything went back
to before accreditation, with only small changes in terms of paperwork.’
These respondents affirmed that accreditation procedures and best practices
should occur every day, not only during the week of accreditation. The respondents
also suggested that the administration was responsible for encouraging employees to
maintain and build quality of care.

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
10 M. ALMASABI AND S. THOMAS

Table 5. Regression analysis results of quality processes and accreditation results

Coefficientsa
Unstandardised Standardised
Model coefficients coefficients
Std.
B error Beta T R2 AR2 Sig.
Step 1
Benefits of .686 .041 .547*** 16.893 .300 .000
accreditation
Step 2
Measurement and .244 .047 .197*** 5.233 .327 .027 .000
analysis
Step 3
Professional .098 .029 .120** 3.406 .339 .012 .001
participation
Step 4
Leadership .094 .045 .084* 2.084 .343 .004 .038
a
Dependent variable: accreditation results. Note:
*p < 0.05,
**p < 0.01,
***p < 0.001.

Staff shortages remain one of the biggest challenges facing accreditation. Half of
the respondents highlighted that while their departments already experienced staff
shortages, the accreditation process required additional staff to deal with the amount
of paperwork. Another theme was the perception of failure to fulfil promises made
during the accreditation process once accreditation was achieved. Some respondents
mentioned that the hospital management promised to decrease their hours of duty af-
ter accreditation, as well as to increase their salaries. However, according to these re-
ports, this did not happen.

Study 2 results
Table 6 shows the results for ORs (with 95% confidence intervals [CI]) of mortality
and infection. In terms of mortality, the results indicate that there was no significant
difference between the mortality rates before and after CBAHI accreditation. In
terms of infection, there were statistically significant differences at all three hospi-
tals. The results of infection were varied among the three. For example, the infection

Table 6. Quality indicator results

Indicator Hospital OR CI p
Mortality A 0.96 0.88–1.04 0.330
B 1.04 0.86–1.26 0.650
C 0.90 0.72–1.11 0.337
Infection A 1.16 1.05–1.27 0.0026
B 0.48 0.38–0.60 0.0001
C 1.60 1.22–2.10 0.0007

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
 THE IMPACT OF SAUDI HOSPITAL ACCREDITATION ON QUALITY OF CARE 11
rate had increased after CBAHI accreditation in Hospitals A and C, whereas in Hos-
pital B, the infection rate had decreased.
The results for LOS were statistically significant for Hospital A and Hospital B
(Table 7). An inspection of the mean scores for Hospital A indicates that LOS was
higher after accreditation than before it, whereas at Hospital B, LOS was lower after
accreditation.

Study 3 results
Thematic analysis of the interview data falls broadly into 5 codes and 23 sub-codes
representing a range of topics, including reasons, challenges, benefits, criticism and
suggestions.

Reasons to join CBAHI

Respondents were aware that CBAHI was a mandatory programme, not a matter of
choice. They reported that pressure from the MOH and the need to restructure hos-
pitals as a result of its policies were decisive in their transition to accreditation.
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.)
Perhaps second only to the mandatory nature of the accreditation process was social
pressure from the community for safe and high-quality services. Our respondents
viewed CBAHI accreditation as a comprehensive tool to address the concerns of
patients and families for quality improvement, patient safety, patient satisfaction
and patients’ needs, as well as to improve the image of the hospitals in Saudi Arabia.
Indeed, a third pressure was globalisation. Respondents believed that accreditation
brought the country into line with an international strategy used by other nations
to foster quality improvement.

Challenges to the process of CBAHI

The most commonly cited challenge to joining CBAHI was resistance to change,
identified by all of the respondents. Some staff did not want to change from the
old systems that they had been used to working with to satisfy new requirements un-
der accreditation.

Table 7. Length of stay (LOS) results

Indicator Hospital Mean F p

LOS A Before 6.71 18.118 0.000
After 7.24
B Before 3.42 4.083 0.048
After 3.15
C Before 4.09 2.850 0.097
After 4.24

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
12 M. ALMASABI AND S. THOMAS

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 natu-
rally 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.)
Most of the respondents agreed that their knowledge of the new standards and prac-
tices for quality was very limited when they started the process. Because of a lack of
knowledge and skills, some staff were uninterested or uncertain about how to intro-
duce these concepts into the hospital. Thus, a majority of senior managers indicated
that lack of staff involvement was a challenge they faced throughout the accredita-
tion process. They claimed that it was difficult in the beginning to involve all staff,
especially physicians and nurses.
When specifically asked about resistance to change, three respondents reported
feeling that the most resistance came from senior staff members and Saudi staff.
They believed that resistance was high among Saudi staff, as they have more secure
employment.
Respondents identified programme language diversity as creating barriers in com-
munication between medical practitioners and patients and among medical personnel
themselves. Staff shortage was another problem. Human resources at the hospitals
were reported as far below the rate required by accreditation standards.

Benefits of CBAHI
Senior managers commended the improvement in the workplace environment as a
result of accreditation by the CBAHI. The respondents stated that conflict at work
had decreased because staff had to follow protocols and standard guidelines, which
in turn enabled hospitals to have a clear mission and vision.
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.)
Many respondents believed that the CBAHI had contributed significantly to the im-
provement of communication, through the availability of policies and procedures
that facilitated greater unity among members of hospital staff.
The reporting and management of medical and non-medical errors had improved
under the CBAHI standards, the majority of respondents reported. They felt that the
new requirements encouraged the administrative leadership of the hospitals to pro-
mote a positive culture of accountability, rather than a punitive culture of blame.
A majority of respondents agreed that an improvement of documentation was a
significant contribution of the CBAHI. CBAHI accreditation encouraged better cler-
ical and record-keeping policies and procedures at the hospitals.

Criticism of CBAHI
Respondents reporting criticisms of CBAHI included more than half of the man-
agers, who mentioned that paperwork had increased as a result of mandatory

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
 THE IMPACT OF SAUDI HOSPITAL ACCREDITATION ON QUALITY OF CARE 13
accreditation. respondents stated that it was difficult for the principles of the CBAHI
to be applied as part of normal hospital routines. The focus on documentation and
data collection were two major barriers to process management. The respondents felt
that staff had to spend much of their private time attending meetings, training and
dealing with CBAHI reports.
Some of the respondents remarked on CBAHI’s strong focus on documentation
and policy manuals, rather than actual clinical practice. The respondents claimed that
this programme put more focus on the hospitals’ physical and structural aspects and
less on clinical practice.
Another problem related to CBAHI is that it is a cross-sectional rather than con-
tinuous improvement. The evaluation was conducted every three years and there
was no monitoring until the next survey.
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.)
Although the majority of respondents criticised aspects of CBAHI accreditation,
three of the respondents stated that there were no disadvantages to CBAHI accredi-
tation. These three respondents saw CBAHI as advantageous because its main aim
was to improve quality of care.

Suggestions to improve CBAHI

Suggestions for improving the current CBAHI programme mostly revolved around
community involvement, leadership and establishing a culture of quality within the
hospital. Some of the respondents declared that there was a barrier between hospitals
and the community, and they urged that the community be involved in hospital
programmes.
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.)
Respondents emphasised the importance of leadership as the primary force behind
quality improvement. Respondents felt that the hospital leadership should support
staff by interacting with them to reinforce the standards on a daily basis. Half of
the respondents deeply believed that having a culture of quality in the hospital would
lead to improvements.

DISCUSSION

The results of this study demonstrate that although some improvements in the proce-
dures 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.

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
14 M. ALMASABI AND S. THOMAS

As literature has indicated that a proper process of care may increase the likeli-
hood of good outcomes, it is not clear whether the improvements in the processes
can be attributed to the accreditation programme. Being accredited does not ensure
this much desired result. In short, the true value associated with accreditation will
only be realised when it can be conclusively shown that it achieves tangible im-
provements in quality of care (El-Jardali 2007).
The fact that we did not find stronger evidence for an added value of the accred-
itation programme may 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 implementa-
tion. 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 partic-
ipate in the accreditation process will be difficult unless accreditation is perceived as
a benefit at a clinical level. Accreditation programmes 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
programmes 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. Some hospitals may reject the requirements
because of their routine nature. This reaction by the hospitals takes place after the
on-site survey, seemingly because of the lack of a comprehensive unannounced visit
programme by the surveyors (Aryankhesal and Sheldon 2010). This point is
supported by Devkaran and O’Farrell (2014), who reported that mandatory accredi-
tation shifts the goal to survey compliance instead of quality improvement, does not
embed the standards into practice and does not sustain performance. Another reason
to reject the requirements may be because of power dynamics, as the results suggest
that native Saudis were less motivated to change. Perhaps native Saudi professionals
were less motivated to change because they were not as concerned about losing their
positions compared to professionals from different backgrounds.
Another possible explanation is that 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).
Furthermore, some physicians feel that they already provide services of high qual-
ity and that there is no need for accreditation. The CBAHI accreditation programme
may be highly effective in changing structures, administrative procedures and
organisational processes, but not as effective in improving the indicators of care that
the researcher measured.
This study illustrates a need to sustain improvements over the accreditation cycle;
this means meeting the immediate accreditation standards, establishing a basis for

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
 THE IMPACT OF SAUDI HOSPITAL ACCREDITATION ON QUALITY OF CARE 15
ongoing quality improvement into the future and providing hospitals with the
prompts and resources required to help them navigate accreditation in order to enable
more productive and long-lasting engagement in quality improvement. Some studies
have highlighted factors that appear to be important in influencing the sustainability
of improvements over the accreditation cycle programmes.
Allowing hospitals to voluntarily sign up for accreditation is encouraged. When
accreditation is voluntary, the pressure to participate may come from within the
organisation. But when participation is mandatory, the pressure comes from outside
the organisation. Thus, the system may shift into a focus based on changing the
system to a regulation instead of self-development (Scrivens 2002).
Transferring from scheduled surveys to an unannounced survey strategy is recom-
mended to create a heightened awareness of the level of compliance and standards.
This strategy causes health organisations to shift the focus from preparing for a
scheduled visit to remaining constantly ready to meet accreditation standards and
to focus on patient care (Greenfield et al. 2012b). Unannounced surveys have for
several years been part of various accreditation programmes, such as the Aged Care
Standards and Accreditation Agency in Australia and the Joint Commission Interna-
tional (JCI) in the United States (Schmaltz et al. 2011). In addition, some accredita-
tion programmes—such as the JCI since 2004—have been using tracer methodology
(Greenfield et al. 2012c). Tracer methodology is an evaluation strategy in which
surveyors select a patient to follow through the organisation, in order to assess that
patient’s care and system process issues for standards compliance (Schmaltz et al.
2011; Murray 2013).
CBAHI standards use traditional accreditation, which focuses on structural evalu-
ation. However, the literature supports a movement to modern accreditation, which
includes all three measures of quality of care—structures, processes and outcomes
—to sustain improvements. This approach offers high levels of assurance about
these three aspects, following the classic model of Donabedian (Donabedian, 1980).
In order to provide a greater understanding of the benefits of accreditation, there is
a growing desire to define performance in terms of clinical outcomes (Scrivens
1998), as the greater use of clinical outcomes indicators would strengthen the evi-
dence base (Hinchcliff et al. 2012b). Incorporating quality indicators into the accred-
itation standards process may have been beneficial for practice in order to maintain a
high level of quality in some areas and further improve in others. Several accredita-
tion programmes have taken steps to incorporate objective, validated measures of
service quality and outcomes into their accreditation standards process. For instance,
the clinical indicator programme of the Australia Council on Healthcare Standards
(ACHS) programme was established to increase the clinical components and indica-
tors in its new accreditation programme (Guérin et al. 2013). More than half of
Australian hospitals are monitoring the indicators and reporting clinical data twice
yearly to the ACHS (Collopy 2000). This strategy encourages health organisations
to continually self-monitor and initiate quality improvement activities (Wagner
et al. 2012) and leads to improvements in both quality processes and outcomes.
In addition, over the last decade, community engagement has received increased
attention in health care (Sarrami-Foroushani et al. 2014)—in accreditation processes
in particular (Nathan et al. 2014a). ACHS explicitly includes community

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
16 M. ALMASABI AND S. THOMAS

participation in its standards (Nathan et al. 2014b). The literature also indicates that
for training to be effective, it needs to be sufficient, continuous, well designed and
well delivered, demonstrably relevant to day-to-day activities and focused on equip-
ping individuals with the understanding and tools to improve the quality of health
care.
Engendering a quality culture in health organisations seems to be a prerequisite
for any meaningful accreditation system that supports continuous quality improve-
ment; this is in contrast to a mechanical process of completing checklists (Al-Shehri
and Al-Alwan 2013).
There is a need for the CBAHI to devise a strategy that involves physicians in the
accreditation process, in keeping with those accreditation programmes worldwide
that already do this. For example, in 2005 the JCI established the Physician Engage-
ment Advisory Group in order to expand physician participation in the accreditation
process and broaden physician engagement in all quality of care and patient safety
initiatives (JCI 2011).
Focusing on continuous quality improvement will also provide greater interest and
engagement, resulting in more sustainable outcomes. For example, the Plan-
Do-Study-Act method will lead to the development of a continual improvement
cycle. It offers a strategy for improving quality of care that avoids stagnation and
declining outcomes by monitoring performance and taking proactive initiatives at
the best time in order to sustain performance (Devkaran and O’Farrell 2014). Also,
measuring patient satisfaction regularly is another important issue. In France, health
organisations are required to evaluate patient satisfaction on a regular basis and use
the results to inform continuous quality improvement (Touati and Pomey 2009).

Strengths and limitations

The main strength of this study is the combination of quantitative and qualitative
data. The study has some limitations: (i) it was carried out in only three hospitals,
therefore the results may not be representative of other hospitals; (ii) accreditation
did not take place concurrently in Hospitals A, B and C; and (iii) the small qualita-
tive sample could limit the generalisability of our findings.

ETHICAL APPROVAL

The study was approved by the Monash University ethics committee and the Minis-
try of Health ethics committee.

ACKNOWLEDGEMENTS

We are indebted to all the hospitals and staff for their invaluable collaboration which
made this research possible.

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
 THE IMPACT OF SAUDI HOSPITAL ACCREDITATION ON QUALITY OF CARE
REFERENCES
Al-Shehri AM, Al-Alwan I. 2013. Accreditation and cul-
ture of quality in medical schools in Saudi Arabia.
Medical Teacher 35: 8–14.
AlKhenizan A, Shaw C. 2010. Assessment of the
accreditation standards of the Central Board for
Accreditation of Healthcare Institutions in Saudi
Arabia against the principles of the International
Society for Quality in Health Care (ISQua). Annals
of Saudi Medicine 30: 386.
Almasabi M. 2013. An overview of quality and accredita-
tion in the health sector within Saudi Arabia. Interna-
tional Journal of Health Research and Innovation 1:
1–5.
Aryankhesal A, Sheldon T. 2010. Effect of the Iranian
hospital grading system on patients’ and general prac-
titioners’ behaviour: an examination of awareness,
belief and choice. Health Services Management
Research 23: 139–144.
Bland JM, Altman DG. 2000. Statistics notes: the odds
ratio. BMJ [British Medical Journal] 320: 1468.
Collopy BT. 2000. Clinical indicators in accreditation: an
effective stimulus to improve patient care. Interna-
tional Journal for Quality in Health Care 12: 211–216.
Creswell J. 2009. Research Design: Qualitative, Quanti-
tative, and Mixed Methods Approaches. Sage Publica-
tions: Thousand Oaks, CA.
Devkaran S, O’Farrell PN. 2014. The impact of hospital
accreditation on clinical documentation compliance: a
life cycle explanation using interrupted time series
analysis. BMJ Open 4: e005240.
Dickison P, Hostler D, Platt TE, Wang HE. 2006. Pro-
gram accreditation effect on paramedic credentialing
examination success rate. Prehospital Emergency Care
10: 224–228.
Donabedian A. 1980. Explorations in Quality Assessment
and Monitoring. Health Administration Press: Ann
Arbor, Mich.
Doyle L, Brady AM, Byrne G. 2009. An overview of
mixed methods research. Journal of Research in Nurs-
ing 14: 175–185.
El-Jardali F. 2007. Hospital accreditation policy in
Lebanon: its potential for quality improvement. Le
Journal Medical Libanais. The Lebanese Medical
Journal 55: 39–45.
El-Jardali F, Jamal D, Dimassi H, Ammar W,
Tchaghchaghian V. 2008. The impact of hospital ac-
creditation on quality of care: perception of Lebanese
nurses. International Journal for Quality in Health
Care 20: 363–371.
Figueras J, Robinson R, Jakubowski E. 2005. Purchasing
to Improve Health Systems Performance. Open Uni-
versity Press: Philadelphia.
Copyright © 2016 John Wiley & Sons, Ltd.
17
Greenfield D, Braithwaite J. 2009. Developing the evi-
dence base for accreditation of healthcare organisa-
tions: a call for transparency and innovation. Quality
and Safety in Health Care 18: 162–163.
Greenfield D, Pawsey M, Braithwaite J. 2012a. The role
and impact of accreditation on the healthcare
revolution/O papel eo impacto da acreditação na
revolução da atenção à saúde. Acreditação 1: 1–14.
Greenfield D, Moldovan M, Westbrook M, et al. 2012b.
An empirical test of short notice surveys in two accred-
itation programs. International Journal for Quality in
Health Care 24: 65–71.
Greenfield D, Hinchcliff R, Westbrook M, et al. 2012c.
An empirical test of accreditation patient journey sur-
veys: randomized trial. International Journal for Qual-
ity in Health Care 24: 495–500.
Guérin S, Le Pogam M-A, Robillard B, et al. 2013. Can
we simplify the hospital accreditation process?
Predicting accreditation decisions from a reduced
dataset of focus priority standards and quality indica-
tors: results of predictive modelling. BMJ Open 3:
e003289.
Hinchcliff R, Greenfield D, Moldovan M, et al. 2012a.
Evaluation of current Australian health service
accreditation processes (ACCREDIT-CAP): protocol
for a mixed-method research project. BMJ Open 2:
1–7.
Hinchcliff R, Greenfield D, Moldovan M, et al. 2012b.
Narrative synthesis of health service accreditation liter-
ature. BMJ Quality & Safety 21: 979–991.
JCI. 2011. Joint Commission International. Facts about
the physician engagement advisory group.
McMillan JH, Schumacher S. 2014. Research in Educa-
tion: Evidence-Based Inquiry. Pearson Higher Ed: Iowa.
Merkow RP, Chung JW, Paruch JL, Bentrem DJ,
Bilimoria KY. 2014. Relationship between cancer cen-
ter accreditation and performance on publicly reported
quality measures. Annals of Surgery 259: 1091–1097.
Murray K. 2013. Are you ready for The Joint Commission
survey? Nursing Management 44: 56.
Nathan S, Stephenson N, Braithwaite J. 2014a.
Sidestepping questions of legitimacy: how community
representatives manoeuvre to effect change in a health
service. Health 18: 23–40.
Nathan S, Braithwaite J, Stephenson N. 2014b. The scope
and impact of community participation: the views of
community representatives in an Australian health ser-
vice. Journal of Health Organization and Management
28: 7–7.
Øvretveit J, Gustafson D. 2002. Evaluation of quality
improvement programs. Quality and Safety in Health
Care 11: 270–275.
Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm
18 M. ALMASABI AND S. THOMAS
Polgar S, Thomas S. 2013. Introduction to Research in the
Health Sciences. Churchill Livingstone Elsevier:
Edinburgh.
Pomey M, Contandriopoulos AP, François P, Bertrand D.
2004. Accreditation: a tool for organizational change
in hospitals? International Journal of Health Care
Quality Assurance 17: 113–124.
Pomey M, Francois P, Contandriopoulos A, Tosh A,
Bertrand D. 2005. Paradoxes of French accreditation.
Quality and Safety in Health Care 14: 51–55.
Pomey M, Lemieux-Charles L, Champagne F, et al. 2010.
Does accreditation stimulate change? A study of the
impact of the accreditation process on Canadian
healthcare organizations. Implementation Science 5:
1–14.
Sarrami-Foroushani P, Travaglia J, Debono D,
Braithwaite J. 2014. Key concepts in consumer and
community engagement: a scoping meta-review.
BMC Health Services Research 14: 250.
Sax S, Marx M. 2013. Local perceptions on factors
influencing the introduction of international healthcare
accreditation in Pakistan. Health Policy and Planning
1: 084.
Schmaltz SP, Williams SC, Chassin MR, Loeb JM,
Wachter RM. 2011. Hospital performance trends on
national quality measures and the association with
Copyright © 2016 John Wiley & Sons, Ltd.
joint commission accreditation. Journal of Hospital
Medicine 6: 458–465.
Scrivens E. 1997. Putting continuous quality improve-
ment into accreditation: improving approaches to qual-
ity assessment. Quality in Health Care 6: 212–218.
Scrivens E. 1998. Widening the scope of accreditation—
issues and challenges in community and primary care.
International Journal for Quality in Health Care 10:
191–197.
Scrivens E. 2002. Accreditation and the regulation of qual-
ity in health services. In Regulating Entrepreneurial
Behaviour in European Health Care Systems, Figueras
J (ed). Open University Press: Philadelphia; 91.
Shortell SM, O’Brien JL, Carman JM, et al. 1995.
Assessing the impact of continuous quality
improvement/total quality management: concept ver-
sus implementation. Health Services Research 30: 377.
Touati N, Pomey MP. 2009. Accreditation at a crossroads:
are we on the right track? Health Policy 90: 156–165.
Wagner LM, McDonald SM, Castle NG. 2012. Joint
Commission accreditation and quality measures in
US nursing homes. Policy, Politics & Nursing Practice
13: 8–16.
Zhang W, Creswell J. 2013. The use of “mixing” proce-
dure of mixed methods in health services research.
Medical Care 51: 51–57.
Int J Health Plann Mgmt 2016
DOI: 10.1002/hpm