Professional Documents
Culture Documents
Ijhcqa 08 2017 0150
Ijhcqa 08 2017 0150
information about how to choose which publication to write for and submission guidelines are available for all. Please
visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of
more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online
products and additional customer resources and services.
Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication
Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation.
Author 1: Mohammad Saadati, Health Services Management, PhD Candidate, Health Services
Management Department, Tabriz University of Medical Sciences, Tabriz, Iran,
Telephone: +984133351048, E-mail: hcm.2020@gmail.com
Author 2: Mohammadkarim Bahadori, Health Services Management, Associate Professor,
Health Policy Manager, Health Policy Department, Health Management Research
Center, Baqiyatallah University of Medical Sciences, Tehran, Iran, Telephone:
+982182482524, E-mail: bahadorihealth@gmail.com
Author 3: Ehsan Teymourzadeh, Health Services Management, Assistant Professor, Research
Manager, Health Policy Department, Health Management Research Center,
Baqiyatallah University of Medical Sciences, Tehran, Iran, Telephone: +982182482524,
E-mail: ehsanteymoorzadeh@yahoo.com
Downloaded by University of Sussex Library At 02:47 02 August 2018 (PT)
Acknowledgements: The researchers thank all study participants for their help during data
collection and analysis.
Abstract
Purpose: Accreditation helps to ensures safe and high-quality services in hospitals. Different
occupational groups have various hospital accreditation experiences. Our study aimed to
investigate nurses' accreditation experience and its effects on Iranian teaching hospital service
quality.
Design/Methodology/Approach: This was a qualitative study involving a phenomenological
approach to studying nurses' hospital accreditation experience and understanding the effects on
Iranian teaching hospital service quality. Data were collected using two focus groups in which
nurses were selected using purposive sampling. Transcripts were analysed using content
analysis.
Findings: Nurses' experiences showed that hospital administrators and nurses had greater role in
implementing accreditation than other occupational groups. Accreditation improved patient-
centeredness, patient safety, logistics and managerial processes, and decision making. However,
a weak incentive system, extra documentation and work stress were negative experiences.
Practical implications: Nurse experience, as the most important care team member, reveals
accreditation’s strengths and weaknesses and its effects on service quality.
Originality/value: We used a phenomenology approach to measure accreditation effects on
service quality - a valuable tool for understanding a phenomenon among those that experience
hospital accreditation processes.
Introduction
Downloaded by University of Sussex Library At 02:47 02 August 2018 (PT)
Quality improvement plays an important role in health system policies in all countries and force
governments to improve health service quality (Campbell et al., 2002; Moss et al., 2000;
Moghria et al., 2013). Accreditation is a common strategy for improving healthcare standards
and has attracted government, healthcare organization, medical association, manager, insurance
company and other stakeholder attention (Scrivens, 1996). Accreditation is a process in which
health service providers are evaluated and accredited by experts from an independent
organization based on written, comprehensive and predetermined standards, and, accordingly,
which leads to providers being awarded an accreditation certificate (Raeisi et al., 2006).
Accreditation should ideally be outside government control. Independent accreditation staff
should evaluate and accredit healthcare organizations, especially hospitals, comprehensively
(Shaw, 2001).
Studies show that accreditation is a tool for improving patient safety and service quality
(Hirose et al., 2003; Braithwaite et al., 2010; Rvangard et al., 2017), which should lead to an
increase in quality management functions and, ultimately, to improved quality (Paccioni et al.,
2008; Huang et al., 2009). A study in 3891 US hospitals showed that hospital accreditation had
positive effects on performance and clinical services (Schmaltz et al., 2011). Other stuidies show
that external accreditation can result in modestly better hospital performance (Lutfiyya et al.,
2009) and hospital accreditation positive effects on services from nurses' viewpoints (Yildiz and
Kaya, 2014; El-Jardali et al., 2008). However, accreditation studies on organizational and
clinical outcomes are unclear (Shaw, 2001; Greenfield and Braithwaite, 2008; Greenfield and
Braithwaite, 2009). Poor manager commitment to and employees' inadequate knowledge of
accreditation are the most important challenges in Iran (Saadati et al., 2015). One study indicated
that the positive effects on service delivery can be created by improving infrastructure, choosing
the right accreditation model, increasing stakeholder cooperation and designing appropriate
information systems in Iranian hospitals (Karimi et al., 2013).
Because the accreditation program requires a workforce and other resources, and its
inconsistent impacts on quality, the need for conducting more studies on accreditation and its
effects on service quality has increased (Shaw, 2001; Yildiz and Kaya, 2014; Greenfield and
Braithwaite, 2008). Researchers suggest that accreditation should be studied in Iran from
different stakeholder perspectives (Bahadori and Hosseini, 2017). Therefore, we aimed to
investigate nurses' experience with accreditation and its effects on Iranian teaching hospital
service quality. Investigating accreditation and its effects on process improvement, and other
professional group roles in accreditation from the nurses' perspective were our objectives.
Methods
We implemented a qualitative study using a phenomenological approach to studying nurses'
experience with and understanding of hospital accreditation in an Iranian teaching hospital in
2016. This hospital had 154 beds and received ‘grade 1 excellent’ in the accreditation program
implemented by Iran's Ministry of Health and Medical Education in 2014 and 2016. The hospital
was among ten grade 1 institutions in Iran. The quality improvement activities, in accordance
with accreditation standards, started in 2011 with senior manager planning and participation. We
collected data using two focus groups (seven and eight nurses), which were held in the hospital.
Nurses were selected using purposive sampling. Inclusion criteria were more than two years’
work experience and an active role in implementing the accreditation program. Each focus group
lasted one hour. First, the study objectives were explained to participating nurses and then
discussions started. Five topics were explored:
Downloaded by University of Sussex Library At 02:47 02 August 2018 (PT)
If participants confirmed saturation, then the next topic was raised. To comply with the ethical
considerations, participation was voluntary, and all participants were assured confidentiality.
Also, to prevent identifying participants, codes were used. Note-taking during the sessions was
done by a researcher. After obtaining participants' consent, the sessions were recorded, and after
the session all discussions were carefully transcribed. To ensure data rigor, transcriptions were
checked against notes taken during the sessions. Transcriptions were given to one participant in
each session to check completeness. Manual content analysis extracted the themes and codes.
Results
Most (90%) focus group participants had a bachelor's degree in nursing. Findings emerging from
group discussions were classified according to five main topics, 19 themes and 63 sub-themes.
… accreditation in my mind is equal to the high stress and the large volume of
documentation!! (Participant 4)
Table I here
Marking high-risk medications is one of the reasons for reducing medication errors. I
myself had already picked the wrong drug up from the medication cabinet a few times,
but now such errors have decreased. (Participant 10)
Another said:
… patient education was already very poor. Now providing education for the patients at
the time of admission and discharge as well as during service delivery has caused
patients to be discharged from the hospital with more satisfaction. (Participant 8)
Downloaded by University of Sussex Library At 02:47 02 August 2018 (PT)
Table II here
... the presence and cooperation of senior managers in the activities and their support for
the implementation of accreditation standards heartened us ... (Participant 5).
However, some nurses believed that physicians and hospital administrators did not play an active
role in the teamwork:
Some of the hospital guards [someone whose job is to protect the hospital and its
employees] cooperated in the accreditation activities and processes more than some
physicians. (Participant 2)
In spite of the poor financial incentive system, the moral support and amenities for
employees such as providing free health services for employees, providing amenities at
the workplace, setting up family camps, etc., have increased after implementing the
accreditation program and achieving the standards. (Participant 12)
The rate of phlebitis was high in our ward. We defined an indicator and designed a data
collection form and collected the related data. Then, we monitored its rate in a three-
month period. Next, using the information obtained and in collaboration with the nurses
working in the ward, the quality improvement program was written and, accordingly,
we could reduce the rate of phlebitis. (Participant 14)
Table IV here
Downloaded by University of Sussex Library At 02:47 02 August 2018 (PT)
Discussion
Nurses had different experiences implementing the teaching hospital accreditation program.
Senior manager and nurse roles, poor cooperation among physicians and administrative staff,
superfluous documentation and a poor incentive system were some items that nurses experienced
during the accreditation process. Results showed positive effects on hospital service quality from
the nurses' perspective, which was like the results from a similar study on accreditation effect on
teaching hospital health service delivery (Moradi et al., 2015). The Schmaltz et al., (2011) and
Lutfiyya et al., (2009) studies indicated that hospital performance improved through
implementing accreditation programs. In another study in 110 hospitals in Lebanon, most
hospital managers considered accreditation a good and useful investment (Saleh et al., 2013).
Other studies did not show any significant relationships between accreditation and service
quality (Sack et al., 2010; Dean Beaulieu and Epstein, 2002; Miller et al., 2005). The difference
between these studies may be due to the instruments used to assess accreditation program effects
on service quality, study methods and context.
Nurses' patient safety experience, such as reducing medical and medication errors,
observing hand hygiene standards, clarifying processes, empowering employees, improving
patient identification, respecting patients and observing their rights, and improving the support,
logistics and managerial processes, demonstrates accreditation’s positive effects on service
quality. Several studies point out that accreditation is a tool for improving quality, safety and
quality management activities (Hirose et al., 2003; Paccioni et al., 2008). Standardizing and
documenting processes, clarifying policies and roles, professional development and using
clinical guidelines for treating patients are some advantages (Greenfield and Braithwaite, 2008;
Touati and Pomey, 2009). Studies indicate the constructive role hospital written protocols and
policies have on service provision (Hartley et al., 2002). However, in our study, nurses
complained about excessive documentation and felt that accreditation was a bureaucratic
process, confirmed in Staniland's (2009) study. In another study, nurses considered
documentation boring, stressful and an extra activity (Sadeghi-Bazargani et al., 2015). Bahadori
et al., (2015) in their study mentioned that focusing too much on documentation is one criticism
leveled against the Iranian accreditation process. Intelligent computer systems, unifying and
integrating policies and protocols by staff in academic centers, and decreases in extra
bureaucracy, can reduce documentation. Also, such bureaucratic processes can reflect weak
human resource management (HRM) and solving this problem requires improvements in HRM
processes, such as the establishing an appropriate and fair incentive system.
In our study, senior manager support for implementing the accreditation program was a
driver felt by nurses, confirmed by El-Jardali et al., (2008); results showed that managing and
leading quality improvement activities in medium-sized hospitals (100 to 200 beds) had the
greatest impact on achieving accreditation. Encouraging employees to take responsibility for
providing safe and high-quality service requires active and effective leadership at all
organizational levels (Balding, 2005; Ravangard et al., 2015). Because our study took place in a
teaching hospital, it seemed that regular frameworks and command structure could be an
accreditation program strength. Yildiz and Kaya (2014) concluded that employee participation
plays an important role in achieving accreditation. Consequently, accreditation programs should
be supported by different occupational groups (Grenade and Boldy, 2002; Casey and Klingner,
2000). Our study showed that nurses believed hospital physicians cooperated poorly in
implementing the accreditation program. Pomey et al., (2004) noted that physicians believed
accreditation was an administrative activity and only nursing managers and other employees
Downloaded by University of Sussex Library At 02:47 02 August 2018 (PT)
should cooperate in its implementation. Poor cooperation when implementing the accreditation
program was also referred as a negative point and weakness in Touati and Pomey's (2009) study.
Poor cooperation from physicians has been evident in voluntary and compulsory accreditation
programs (Pomey et al., 2004). Therefore, hospital administrators should use motivational tools
and incentive systems to increase employee participation, especially physicians, because they are
essential to ensuring standards.
Weak HRM and low employee motivation were also issues raised by nurses. Australian
health care institutions use accreditation as an HRM tool (Greenfield et al., 2014). Developing an
appropriate and fair incentive system, based on employee performance, can eliminate
discrimination and meet employee expectations (Bahadori et al., 2013). Studies show that
information use by hospital staff is significantly associated with quality improvement activities
in accredited hospitals (El-Jardali et al., 2008). Information for improving hospital processes is
an internal factor leading to successful accreditation (Ng et al., 2013). This issue was
experienced by nurses using information to improve clinical processes in their ward (e.g.,
phlebitis control, hand hygiene, etc.) and developing their wards’ quality improvement plans.
Nurses' experience with teaching hospital accreditation provided useful information for
running hospital accreditation processes. Accreditation has positive impacts on hospital service
quality; i.e., patient safety, patient-centeredness and hospital process improvement. However,
hospital managers should identify negative experiences and implement appropriate policies such
as standardizing the nursing workforce, promoting nurses based on quality improvement
indicators, using an appropriate payment method for nurses, improving the relationship between
physicians and nurses, and increasing physician’s accreditation role (Bahadori et al., 2010;
Bahadori et al., 2015).
References
Bahadori, M., Babaei, M. and Mehrabian, F. (2013), ‘Prioritization factors influencing job
motivation in employees of a military center using Analysis Hierarchy Process (AHP)’,
Journal of Military Medicine, Vol. 44 No. 2, pp. 237-244.
Bahadaori, M. and Hosseini, S. M. (2017), ‘Whether Hospital Accreditation Has Led to
Improvement of Care Quality in Iran or not?’, Hospital Practices and Research, Vol. 14
No. 4, p. 1.
Bahadori, M., Ravangard, R. and Alimohammadzadeh, K. (2015), ‘The accreditation of hospitals
in Iran’, Iranian Journal of Public Health, Vol. 44 No. 2, pp. 295-296.
Bahadori, M., Tofighi, S., Ameriun, A., Ravangard, R., Abasi, A. and Jalalian, M. (2010),
‘Evaluation of input indicators related to human resource productivity in a military
hospital in Iran’, HealthMED, Vol. 4 No. 2, pp. 323-327.
Balding, C. (2005), ‘Strengthening clinical governance through cultivating the line management
role’, Australian Health Review, Vol. 29 No. 3, pp. 353-359.
Braithwaite, J., Greenfield, D., Westbrook, J., Pawsey, M., Westbrook, M., Gibberd, R. and
Runciman, B. (2010), ‘Health service accreditation as a predictor of clinical and
organisational performance: a blinded, random, stratified study’, Quality and Safety in
Health Care, Vol. 19 No. 1, pp. 14-21.
Campbell, S. M., Sheaff, R., Sibbald, B., Marshall, M. N., Pickard, S., Gask, L., Halliwell. S.,
Rogers, A. and Roland M. O. (2002), ‘Implementing clinical governance in English
primary care groups/trusts: reconciling quality improvement and quality assurance’,
Quality and Safety in Health Care, Vol. 11, pp. 9-14.
Downloaded by University of Sussex Library At 02:47 02 August 2018 (PT)
Casey, M. and Klingner, J. (2000), ‘HMOs serving rural areas: experiences with HMO
accreditation and HEDIS reporting’, Managed Care Quarterly, Vol. 8 No. 2, pp. 48-59.
Dean Beaulieu, N. and Epstein, A.M. (2002), ‘National Committee on Quality Assurance health-
plan accreditation: predictors, correlates of performance, and market impact’, Medical
Care, Vol. 40 No. 4, pp. 325-337.
El-Jardali, F., Jamal, D., Dimassi, H., Ammar, W. and Tchaghchaghian, V. (2008), ‘The impact
of hospital accreditation on quality of care: perception of Lebanese nurses’, International
Journal for Quality in Health Care, Vol. 20 No. 5, pp. 363-371.
Greenfield, D. and Braithwaite, J. (2008), ‘Health sector accreditation research: a systematic
review’, International Journal for Quality in Health Care, Vol. 20 No. 3, pp.172-183.
Greenfield, D. and Braithwaite, J. (2009), ‘Developing the evidence base for accreditation of
healthcare organisations: a call for transparency and innovation’, Quality & Safety in
Health Care, Vol. 18 No. 34, pp.162-163.
Greenfield, D., Kellner, A., Townsend, K., Wilkinson, A. and Lawrence, S. A. (2014), ‘Health
service accreditation reinforces a mindset of high-performance human resource
management: lessons from an Australian study’, International Journal for Quality in
Health Care, Vol. 26 No. 4, pp.327-377.
Grenade, L. and Boldy, D. (2002), ‘The accreditation experience: views of residential aged care
providers’, Geriaction, Vol. 20 No. 1, pp. 5-9.
Hartley, A., Griffiths, R. and Saunders, K. (2002), ‘An evaluation of clinical governance in the
public health departments of the West Midlands Region’, Journal of Epidemiology and
Community Health, Vol. 56 No. 8, pp. 563-568.
Hirose, M., Imanaka, Y., Ishizaki, T. and Evans, E. (2003), ‘How can we improve the quality of
health care in Japan? Learning from JCQHC hospital accreditation’, Health Policy, Vol.
66 No. 1, pp. 29-49.
Huang, CI., Wung, C. and Yang, C.M. (2009), ‘Developing 21st century accreditation standards
for teaching hospitals: the Taiwan experience’, BMC Health Services Research, Vol. 9,
pp. 232-243.
Karimi, S., Gholipour, K., Kordi, A., Bahmanziari, N. and Shokri, A. (2013), ‘Impact of
Hospitals Accreditation on Service Delivery from The Perspective Views of Experts: A
Qualitative Study’. Journal of Payavard Salamat, Vol. 7 No. 4, pp. 337-353.
Lutfiyya, M.N., Sıkka, A., Mehta, S. and Lipsky, M.S. (2009), ‘Comparison of US accredited
and nonaccredited rural critical access hospitals’, International Journal for Quality in
Health Care, Vol. 21 No. 2, pp. 112-118.
Miller, M.R., Pronovost, P., Donithan, M., Zeger, S., Zhan, C., Morlock, L. and Meyer GS.
(2005), ‘Relationship between performance measurement and accreditation: implications
for quality of care and patient safety’, American Journal of Medical Quality, Vol. 20 No.
5, pp. 239-252.
Moghria, J., Nateghib, E., Araba, M., Moghri, M., Saria, A. A., Omranikhooa, H., Vafayi Najjar,
A. and Ebadifard Azar, F. (2013), ‘Measurement of Patient Safety Culture in Iranian
hospitals: A National Baseline Study’, Journal of Clinical Research and Governance,
Vol. 2 No. 2, pp. 47-52.
Moradi, R., Nemati, A., Bahman Ziari, N., Shokri, A., Mohammadi, M. and Soltantajiyan, A.
(2015), ‘Effect of Accreditation on the Health Services Delivering in University
Downloaded by University of Sussex Library At 02:47 02 August 2018 (PT)
Touati, N. and Pomey, M.P. (2009), ‘Accreditation at a crossroads: are we on the right track?’,
Health Policy, Vol. 90 No. 2, pp.156-165.
Yildiz, A. and Kaya, S. (2014), ‘Perceptions of nurses on the impact of accreditation on quality
of care: a survey in a hospital in Turkey’, Clinical Governance: An International Journal,
Vol. 6 19. No 2, pp. 69-82.
Table IV: Using information for planning and quality improvement: nurses' perspectives
Downloaded by University of Sussex Library At 02:47 02 August 2018 (PT)