Case study YE
Karikari
90E402F6-C155-455F-B072-EF1980145863.pdf
The impact of accreditation on healthcare quality improvement: a qualitative case study
Melo, S. (2016). The impact of accreditation on healthcare quality improvement: a qualitative case study. Journal of Health, Organisation and Management, 30(8), 1242 - 1258. https://doi.org/10.1108/JHOM-01-2016-0021
Published in: Journal of Health, Organisation and Management
Document Version: Peer reviewed version
Queen's University Belfast - Research Portal: Link to publication record in Queen's University Belfast Research Portal
Publisher rights © Emerald Group Publishing Limited 2016. Published by Emerald Group Publishing Limited This work is made available online in accordance with the publisher’s policies.
General rights Copyright for the publications made accessible via the Queen's University Belfast Research Portal is retained by the author(s) and / or other copyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associated with these rights.
Take down policy The Research Portal is Queen's institutional repository that provides access to Queen's research output. Every effort has been made to ensure that content in the Research Portal does not infringe any person's rights, or applicable UK laws. If you discover content in the Research Portal that you believe breaches copyright or violates any law, please contact [email protected].
Download date:25. Mar. 2020
Journal of H ealth O
rganization and M anagem
ent
The impact of accreditation on healthcare quality
improvement: a qualitative case study
Journal: Journal of Health Organization and Management
Manuscript ID JHOM-01-2016-0021.R2
Manuscript Type: Original Article
Keywords: hospital accreditation, healthcare quality management, patient safety, case study
Journal of Health Organization and Management
Journal of H ealth O
rganization and M anagem
ent
1
The impact of accreditation on healthcare quality improvement: a
qualitative case study
Abstract
Purpose
Research on accreditation has mostly focused on assessing its impact using large scale
quantitative studies, yet little is known on how quality is improved in practice through an
accreditation process. Using a case study of an acute teaching hospital in Portugal, the article
aims at exploring the dynamics through which accreditation can lead to an improvement in
the quality of healthcare services provided.
Design/methodology/approach
Data for the case study was collected through 46 in-depth semi-structured interviews with 49
clinical and non-clinical members of staff. Data were analysed using a framework thematic
analysis.
Findings
Interviewees felt that hospital accreditation contributed to the improvement of healthcare
quality in general, and more specifically to patient safety, as it fostered staff reflection, a
higher standardization of practices, and a greater focus on quality improvement. However,
findings also suggest that the positive impact of accreditation resulted from the approach the
hospital adopted in its implementation as well as the fact that several of the procedures and
practices required by accreditation were already in place at the hospital, albeit often in an
informal way.
Research limitations/implications
The study was conducted in only one hospital. The design of an accreditation implementation
plan tailored to the hospital’s context can significantly contribute to positive outcomes in
terms of quality and patient safety improvements.
Originality/value
This study provides a better understanding of how accreditation can contribute to healthcare
quality improvement. It offers important lessons on the factors and processes that potentiate
quality improvements through accreditation.
Page 1 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
2
Introduction
Healthcare quality improvement is one of the key priorities of health systems worldwide
(Chassin, 2013). Influenced by the developments on quality management in the
manufacturing industry, continuous quality improvement also became a major area of
concern in the healthcare sector, particularly since the 1980s (Boaden, 2005; Graham, 1995;
Kilo, 1998). In the late 1990s, this focus on quality management, and more specifically on
patient safety, gained a new impetus with the publication of reports such as To Err is Human
(Kohn et al., 2000) which alongside highlighting the magnitude of adverse events, argued
about the possibility of preventing a significant number of them (Vincent, 2011). As a result,
several initiatives have been adopted in order to improve the quality of care provided,
including total quality management (McLaughlin and Kaluzny, 2004), plan-do-study-act
(Taylor et al., 2014), collaboratives (Schouten et al., 2008), statistical process control (Thor
et al., 2007), and six sigma (DelliFraine et al., 2010).
Amongst the quality initiatives adopted in healthcare, accreditation has increasingly been
considered as the preferred method to promote healthcare quality at organisational and
service levels (Shaw et al., 2010), given its wide reputation as a key driver for healthcare
quality and patient safety improvement (Braithwaite et al., 2010; Rooney and Van Ostenberg,
1999). Despite the significant expenses associated with accreditation, hospitals consider it as
a worthy investment (Saleh et al., 2013). Accreditation’s perceived value in improving
healthcare quality has led to the establishment of mandatory accreditation programmes in
countries such as Iran (Jaafaripooyan, 2011), Italy, Scotland and France (World Health
Organisation, 2003).
On the whole, evidence suggests that hospitals which have embarked on accreditation
programmes have higher performance in comparison with those which have not (Shaw et al.,
2010). In a random sample of 23 hospitals in Australia, it was found that the hospitals that
had applied for accreditation performed better in terms of administration and management,
medical staff organisation, organisation of nursing services, review systems, physical
facilities and safety, and hospital role definition and planning (Duckett, 1983). In a systematic
review involving 66 studies, Greenfield and Braithwaite (2008) found consistent findings that
accreditation contributed to promote change and professional development.
However, notwithstanding the commonly accepted perceptions by governments (El-Jardali et
al., 2008) and healthcare professionals (Diab, 2011; El-Jardali et al., 2008) on the benefits of
accreditation; existing evidence is either modest (Hinchcliff et al., 2012; Lutfiyya et al.,
Page 2 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
3
2009) or inconclusive (Bogh et al., 2015; Braithwaite et al., 2010; Dean Beaulieu and
Epstein, 2002; Greenfield and Braithwaite, 2008; Miller et al., 2005; Shaw et al., 2010;
Thornlow and Merwin, 2009), particularly regarding its impact on the quality of care. For
example, findings from a study of 216 state psychiatric hospitals in the U.S. revealed a weak
association between accreditation and the seven indicators of quality of care selected (average
cost per patient, per diem bed cost, total staff hours per patient, clinical staff hours per
patient, percent of staff hours provided by medical staff bed turnover, and percent of beds
occupied) (Hadley and McGurrin, 1988). Data from a randomised control trial involving 20
South African hospitals (Salmon et al., 2003) showed that although accreditation had a
positive effect on nurses’ perception of clinical quality, it had little or no effect in the
remaining seven quality indicators selected (client satisfaction, client medication education,
accessibility and completeness of medical records, quality of perioperative notes, hospital
sanitation, and labelling of ward stocks).
As a result of this lack of robust empirical evidence on the impact of implementing
accreditation standards (Greenfield et al., 2012) as well as little knowledge on accreditation’s
implementation process (Hinchcliff et al., 2013), several calls for further research how
accreditation programmes affect the structure, process and outcomes of hospital care have
been made (e.g. Greenfield and Braithwaite, 2008; Hinchcliff et al., 2012; Pomey et al.,
2004; Shaw et al., 2010). Specifically, the link between accreditation and hospital healthcare
quality has remained under-studied (Schmaltz et al., 2011) as well as the processes through
which accreditation “might lead to improved quality of care, strengthen leadership culture
and climate, and how these factors in turn might mediate accreditation performance”
(Braithwaite et al., 2010:19).
This article presents an in-depth qualitative study of an acute hospital which embarked on an
accreditation programme. The central aim of the research was to explore the mechanisms
through which the accreditation process resulted in quality improvement. By exploring the
factors that facilitated or hindered the impact of accreditation’s implementation process on
quality and patient safety improvements, this study contributes to the understanding of the
reasons behind accreditation’s mixed results, often found in systematic synthesis of
accreditation literature (e.g. Greenfield et al., 2012). In doing so, it also adds to the
theoretical development of the accreditation literature (Hinchcliff et al., 2012). From a
practitioner’s point of view, the results of the article will help healthcare managers to attain
higher quality improvements from the implementation of hospital accreditation.
Page 3 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
4
Research Methodology
This study adopts a qualitative case study of an acute teaching hospital in Portugal. The case
study research method was chosen given its advantages for the analysis of qualitative
complex events (George and Bennett, 2005), its capacity to obtain detailed information about
the case in analysis (Hammersley, 2001) and the ability to deal with a wide range of sources
of evidence, such as documents and interviews (Yin, 2013).
The case study hospital was purposively selected (Maxwell, 2012) given that it is recognised
as one of the pioneer hospitals in Portugal adopting quality and patient safety improvement
initiatives. Data were mainly collected using semi-structured interviews. Interviews are
considered as one of the key sources of evidence within qualitative case studies (Yin, 2013).
The first round of eight interviews took place in June 2009 and involved nine interviewees. It
provided information on the historical context of the hospital’s increased emphasis on quality
and patient safety improvement. Interview questions focused on exploring the key drivers for
the establishment of quality and patient safety improvement as a hospital priority; the main
quality and patient safety initiatives adopted and the role of the different departments and
hospital staff in their design and implementation; as well as the impact that the organisational
structure, internal processes and organisational culture had on the entire process.
The second stage of 38 interviews involving 41 interviewees was conducted between
December 2009 and January 2010 and focused on the details of specific patient safety
projects such as falls prevention and the improvement of the hospital’s accessibility. The
selection of these projects was decided by the researcher and was motivated by several
factors. Above all, data gathered during the first stage of interviews suggested that falls
prevention initiatives were one of the biggest patient safety projects adopted by the hospital
in terms of the timeframe, range of activities, and number of departments and staff involved.
Although the accessibility project was considered by interviewees a much smaller scale
project in terms of staff directly involved, interviewees recognized its significant impact on
the quality of care provided and overall patient experience. Second, given the non-clinical
background of the interviewer, both projects seemed to be appropriate subjects of study as
they would not require the researcher to obtain clinical knowledge in order to be able to
collect and analyze data. Finally, both projects were relatively recent initiatives. This
increased the possibility of interviewing staff that had been involved at the beginning of the
projects and facilitated interviewees’ recalling of past events associated with the projects;
Page 4 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
5
which were considered as important contributors towards ensuring an appropriate level of
trustworthiness of the interview data collected.
Themes covered in the second stage of interviews included the reasons for the adoption of the
specific projects studied and the factors that influenced both their design and implementation
across the hospital’s departments. In both stages, the impact of accreditation in quality
improvement was an important issue.
Given the outsider nature of the interviewer and the resultant unfamiliarity with the hospital
setting, adopting a staged-research was considered to be the best strategy to achieve an in-
depth understanding of the case study. The initial collection of contextual information on the
hospital’s quality and patient safety initiatives was subsequently used to frame the research in
terms of the choice of projects to focus on. Pragmatically, conducting research in a staged
way also facilitated the hospital’s ethics approval process.
In total, 46 interviews, involving 49 interviewees (30 women and 19 men) were conducted.
One of the interviewees was interviewed twice, given their membership in the quality
management department and knowledge on specific patient safety projects researched. The
first interview took place during the first stage of data collection and focused on the
hospital’s quality and patient safety initiatives and the role played by the quality management
department in such activities. The second interview was conducted during the second stage of
data collection and explored specific patient safety projects.
Overall, interviews lasted from 12 to 120 minutes and the average duration was 43 minutes.
In order to gain as broad a picture as possible of the quality improvement projects,
respondents were selected from an array of departments and professional roles. Interviews
were conducted with 25 nurses, eight doctors, four nurse aides, three engineers, two
administrative staff, two health and safety technicians, two managers, two social workers and
a laboratory technician. These professionals worked in several clinical and non-clinical
departments, including cardiology, accidents and emergency, general surgery, sterilization,
premises and equipment, quality management department, catering services, human resource
department, social services, and customer care department. The vast majority of interviewees
were directly involved in quality and patient safety initiatives in their day to day job. In order
to better understand hospital staff’s involvement in quality and patient safety initiatives, the
interviewer also conducted some interviews with staff whose activity is not directly related
with quality and patient safety issues (e.g. administrative staff). These interviews aimed at
Page 5 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
6
checking the extent which quality and patient safety initiatives were known across the
hospital. As a result, some of the interviews conducted were of shorter duration.
Interviews took place at the department were interviewees work and were conducted in
Portuguese. In each of the stages, all interviews followed the same interview schedule;
however not all interviews covered all the questions. The exact questions asked to each
interviewee depended on their involvement with and knowledge of quality and patient safety
projects, as demonstrated by their responses to previous questions. All interviews but four
(one in the first stage and three in the second stage) were individual interviews. Interviews
with two professionals took place due to pragmatic reasons such as office sharing. Whereas
joint interviews have the advantage of interviewees jointly contributing to the story and thus
filling in the gaps in the narrative (Morris, 2001), the interaction during the interview may be
influenced by the preexisting relationship between interviewees (Morris, 2001), which can
result in one interviewee dominating the interview or silencing the other’s account (Polak and
Green, 2016). Notwithstanding the limitations of joint interviewing, the interviewer felt that
conducting joint interviews did not impact interviewees’ responses. Interviewees were
approached using a snowball approach, whereby interviewees suggested other hospital staff
considered relevant for the case study (Black, 2002).
All interviews but two were audio-recorded and verbatim transcribed by the researcher. In the
remaining two interviews interviewees asked to not be recorded and thus detailed notes were
taken. Data from interviews was supplemented by data from statistics, annual reports,
presentations provided by the hospital as well as information on the hospital published in
magazines, the hospital’s website and documents from the Portuguese Ministry of Health.
The ways additional information was analyzed and used to inform the research varied
according to the source. At the beginning of the research, the hospital’s website was browsed
in order for the researcher to become acquainted with the hospital’s context in terms of its
organizational structure, healthcare provision, quality and patient safety initiatives adopted,
etc. Documents from the Ministry of Health, articles published in magazines, and hospital’s
annual reports helped to understand the Portuguese National Health Service as well as how
the hospital compared with other public hospitals regarding quality and patient safety
projects. Given that the objective of using these sources was to obtain a general overview of
the case study’s context, their analysis followed an unstructured approach in which the author
read the sources and took notes of the information considered relevant for the study.
Page 6 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
7
By contrast, statistics and presentations provided by the hospital during the first stage of
interviews were used by the author to obtain further details on aspects discussed during the
interviews. For example, photographs included in the presentations helped the interviewer to
visualize changes made to the built environment as part of quality and patient safety projects.
Interview data were open-coded and analysed using a framework thematic analysis (Spencer
et al., 2014). As Spencer et al. (2014) describe, the framework thematic analysis, commonly
known as the ‘Framework’ is an analytic tool which in addition to the key steps of the data
management process included in thematic analysis, has the extra phase of ‘data summary and
display’. In this way, data analysis involved:
i) familiarization with the data;
ii) identification of a set of preliminary themes and sub-themes (i.e. the initial thematic
framework). The devised thematic framework included themes such as “advantages
of accreditation” and sub-themes such as “higher formalization”, “accreditation
process as trigger for change”, “bigger role of statistics” and “more formalised
communication”;
iii) indexing and sorting of the data using the devised thematic framework. Indexing and
sorting was made by reading all interview transcripts and writing the themes on the
margins of the transcripts;
iv) review of the themes and sub-themes; and
v) data summary and display. For each theme a table linking the sub-themes with the
data excerpts was created.
All the analysis was conducted by the author. Interview excerpts were translated by the
author and an attempt was made to preserve the original meaning. Computer Assisted
Qualitative Data Analysis Software was not used to manage and organise the data given the
familiarity of the author with the data and to avoid over-extracting the data out of its context
(Agius et al., 2015; Spencer et al., 2014).
Ethics approval to conduct the study was obtained from the hospital and from The University
of York. All participants received an information sheet with details about the study and
signed a consent form before the start of the interview.
Page 7 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
8
Findings
The results first describe the rationale for the hospital to have embarked on the accreditation
process and then discuss how this process led to quality and patient safety improvements.
This analysis takes into account the intrinsic features of accreditation and the specific
characteristics of the accreditation’s implementation process inside the case study hospital.
Rationale for the accreditation process
Interviews suggest that two main inter-related factors motivated the case study hospital to
embark on the accreditation process. Internally, the change of board members in 2000 led to a
more formalised focus on quality improvement. In the words of a non-clinical staff member,
the hospital started to adopt “a philosophy of continuous quality improvement.” As part of
this greater focus on quality improvement, several initiatives aimed at improving the quality
of care were adopted, including the start of the accreditation process in 2000. In the words of
a member of the quality management department, accreditation was perceived as “a code of
good practices” and as “a methodology that somehow could make some transformations in
terms of the quality culture”.
Externally, the hospital’s strategic approach to quality improvement was aided by the
Portuguese Ministry of Health’s own strategy to improve the quality of care provided. In the
late 1990s and early 2000s the Portuguese Ministry of Health established formal agreements
with international bodies to facilitate the quality improvement of the healthcare providers of
the Portuguese National Health Service. Among these was the agreement made with the UK
King’s Fund Health Quality Service (KFHQS) on the 17 th March 1999 (Ribeiro, 2004), which
gave rise to what in Portugal is known as the Programa Nacional de Acreditação dos
Hospitais (National Programme of Hospitals’ Accreditation). Participation in this
accreditation programme was optional and the role of the Ministry of Health was to facilitate
the contact between the KFHQS and Portuguese hospitals.
Impact of the accreditation process
In terms of outcomes, the accreditation process was perceived by interviewees as having
contributed to significant quality and patient safety improvements in the case study hospital.
Several respondents pointed out that accreditation played a key role in the establishment of a
patient safety culture within the hospital. Respondents also felt that accreditation led to a
shared feeling that everyone inside the hospital could play an active role in improving the
quality of care across the hospital:
Page 8 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
9
We have noted a generalisation of this patient safety culture. Staff feel that it is important,
that everyone is involved in patient safety (Member of the quality management
department).
The funny thing is that professionals are very involved in reporting and improving the
quality of their services, i.e., if I am in my clinical unit and I see a less good thing for
patients or for staff, I will communicate that and give a suggestion for improvement.
[This culture] has a positive impact. I think people are more conscious that they can have
an active role and that we can all contribute (Nurse).
One visible result of this strengthening of patient safety culture was the rise in the number of
notifications of patient safety incidents from 254 notifications (in the year 2004) to 846 (in
2006) and 2015 (in 2008). Several interviewees mentioned that staff became more aware of
the importance of reporting incidents even if they were minor incidents.
Evidence from the interviews indicates that several factors contributed to the quality and
patient safety improvements resultant from the accreditation process. Whereas some of these
were intrinsic to the accreditation process itself, others were related to way the hospital
implemented accreditation and/or to the specific characteristics of the hospital.
Factors intrinsic to the accreditation process
Evidence from the interviews suggests that, overall, the accreditation process acted as a
trigger and drive for change towards quality and patient safety improvements and therefore
shaped the hospital functioning in several ways. From the outset, accreditation expedited
change, as obtaining accreditation requires the compliance with a series of requirements:
We implemented some things because we were concerned about the accreditation.
When accreditation [assessment] is approaching, we know we have certain parameters
to meet and so we rush to implement them. This is the reality of our institutions […]
we rush to get everything implemented in order to get the certificate (Nurse).
There are things that are defined in the accreditation [manual] which are mandatory
and we had to create mechanisms to fulfil those requirements (Non-clinical staff
member).
This idea of urgency and speediness associated with the accreditation process was mentioned
by several interviewees and contrasted with their views of slowness and difficulty for change
which were perceived as intrinsic characteristics of hospitals:
Page 9 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
10
[Talking about barriers for the implementation of quality improvement projects]
Inside hospitals, everything is too slow. People are not very receptive to [new] ideas,
people are always busy, people allege lack of time. I think above all is lack of
resources. This is the biggest barrier (Doctor).
A second key characteristic of the accreditation process as a trigger for change was its ability
to draw attention to important areas of healthcare quality that in the early 2000s were not so
popular. An example of this was patient safety which at that time was a topic still in its
infancy both in terms of research and practice. Embarking on the accreditation process was
considered by several interviewees as a key factor for the establishment of a higher patient
safety culture inside the hospital given the emphasis placed on patient safety by the
accreditation manual:
Two thirds of the accreditation manual are related with patient safety (Member of the
quality management department).
Two other examples mentioned by interviewees of quality issues that gained further attention
as a result of the accreditation process were i) a higher focus on developing cross-
departmental strategies to prevent patient falls and ii) changes in the hospital’s physical
infrastructure in order to improve its accessibility for patients (e.g. through the creation of
ramps for wheelchair access, and changes in the decoration and layout of hallways in the new
building in order to facilitate patients to recognise the floor where they are at).
Finally, the accreditation process was also frequently mentioned by interviewees as a force
towards greater formalisation within the hospital. As discussed next, this formalisation –
mainly observed through the increase of written procedures and the development of formal
performance management systems – was considered to have affected the day-to-day clinical
practice in several ways.
The fact that the accreditation required shared written procedures across the hospital in
accordance with accreditation standards was perceived by interviewees as an opportunity for
the improvement of existing procedures, as well as the creation of new ones:
I think that the fact that accreditation requires certain things was advantageous for all
institutions because it meant that if we already have them, great; if we didn’t have or
didn’t have so well, we had to improve (Nurse).
Page 10 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
11
Additionally, the existence of shared written procedures was seen as a catalyst of higher
standardization of routines as well as a driving force towards staff learning and cross-
departmental communication:
The accreditation [process] systematizes the communication and document workflows
a lot. [It] led to the organisation and systematization of procedures. Accreditation has
that huge added value of forcing the existence of routines and documents so that
everyone acts in the same way (Engineer).
It is good for staff to know that procedures are written and available for consultation
in the clinical unit where they work (Non-clinical staff member).
When it is not on paper, we need to be repeating the same thing every day, needn’t
we?! (Non-clinical staff member).
Finally, the higher formalization of procedures was seen as resulting in a better patient
experience:
[Accreditation] led clinical units to have written procedures that are disclosed to all
professionals and made available in folders for everyone to consult. For example,
when an immigrant doesn’t speak Portuguese, we have written information indicating
who can help. A few years ago it was through informal contacts. […] Some written
procedures help us to get closer to patients. This is an example of one (Non-clinical
staff member).
Another aspect associated with the higher formalisation fostered by the accreditation process
was the development of performance management systems including the formal definition
and monitoring of performance targets:
In the [accreditation] there are demands in terms of the monitoring of a series of items
(Non-clinical staff member).
[Before accreditation] staff tried to improve what was possible. [Performance
improvement] was not an institutional policy, let’s say. […] Now it is written, it is an
aim of the [clinical] service. […] It is not only the concern of doing things right, there
are in fact objectives to be taken into account and hence I think that is useful (Non-
clinical staff member).
This department has to meet the objectives set by the board through cascading […]
Since [the hospital] started to participate in the accreditation, we started having
auditing, things started to be streamlined. Although [in the past] staff were concerned
Page 11 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
12
about the quality of care they delivered, for example in terms of falls and risks that
patients incurred in the hospital, I think that the concerns [regarding quality], in such
an organised way, have been stronger since the accreditation started (Nurse).
These responses show a clear move from an informal culture where staff guided their practice
by what they considered to be the right thing to do, into a more formalised environment
where performance objectives are defined at institutional level and then cascaded to
departmental and clinical unit levels. Additionally, the formal monitoring and communication
to clinical units of their performance allowed each clinical unit to know their contribution to
the hospital’s overall objectives. Besides contributing to a reduction of the silo mentality, the
new performance management systems also improved staff’s motivation to contribute to
quality and patient safety improvements, including the notification of patient safety incidents:
With the [formalisation] of the clinical auditing process, clinical auditing started to be
systematised, data started to be treated and [for each clinical unit] a report and an
improvement plan were introduced. Somehow that has improved [the performance of]
clinical units and also motivated professionals to improve what is less good (Member
of the quality management department).
Taken together, the existence of written procedures formally communicated to staff and the
formal monitoring of performance increased staff’s commitment in following the procedures:
In the case of a new procedure being informally implemented staff could say “I am
not going to follow it because nobody told me anything about it”. With formal
communication no one has that kind of justification. They can justify by saying “I am
not following the procedure because I don’t feel like it”, which is different, you see?!
(Nurse).
People have that sense of responsibility of not letting things to be done, because then
we conduct internal audits (Nurse).
Although the features of the accreditation process played a significant role in fostering
quality and patient safety improvements, both the hospital characteristics and the approach
followed in the implementation of the accreditation process were vital for the achievement of
such improvements.
Factors intrinsic to the case study hospital
During the interviews, respondents mentioned a series of specific features of the case study
hospital that contributed to the quality and patient safety improvements achieved through the
Page 12 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
13
accreditation process. One of these facilitators was the autonomy the Portuguese Ministry of
Health gave to the hospital to decide to either embark or not on the accreditation process and
to independently manage the entire accreditation process.
Interviewees felt that this autonomy with which the hospital managed the accreditation
process allowed the hospital to adapt the requirements of the accreditation to its context. One
example of this was the change in the organisational structure. Around the year 2004/2005,
the hospital centralised the existing four services related to quality improvement (quality,
clinical governance, hygiene and safety, and occupational health) under one single
department, the quality management department with a staff of sixteen part-time and full-
time members. Similarly to the other departments inside the hospital, the quality management
department directly reports to the hospital board. In addition of fostering coordination, the
centralisation of all quality activities also helped to give visibility to quality management
inside the hospital:
The creation of the [quality management] department, which in many other hospitals
doesn’t exist with this name and with this structure, also gave more emphasis and
increased [quality] concerns (Nurse).
Another example of the contextualisation was the way the hospital designed the accreditation
procedures. Within the hospital, although the accreditation process was managed by a team of
staff of the quality management department, several thematic working groups were created in
order to develop specific procedures. Each working group was formed by staff from several
departments across the hospital who were actively involved with the topic in question in their
day-to-day activity. This knowledge and experience of the reality on the ground ensured that
procedures were tailored to the hospital’s context:
The standards of the international accreditation manual are then adapted and
implemented with the peculiarities of the hospital. […] The working groups try to
materialize the standards in accordance with the particularities of this hospital (Non-
clinical member of staff).
It is easy to develop work instructions. Without clinicians that is impossible because
we are in a hospital (Doctor).
In addition of adapting the accreditation standards to the overall hospital context, during the
interviews it was clear that the entire accreditation process took into account not only the
particularities of the hospital but also the peculiarities of individual departments. For
example, whereas formalisation of procedures was seen by interviewees as a feature of
Page 13 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
14
accreditation which acted as a facilitating factor to quality and patient safety improvement,
some interviewees noted the potential for adverse effects that could arise from formalisation:
We live overwhelmed with work and form filling (Nurse).
In order to avoid an over formalisation, the team responsible for the accreditation process
closely interacted with the clinical units to seek their views on the procedures before they
were implemented. As a result of this collaborative approach, some procedures were tailored
in order to fit with specific departments. For example, the clinical condition of the maternity
unit patients led to the re-design of the form used to report patient’s falls in order to allow a
more detailed reporting of less severe falls. Similarly, it was decided to assess the accidents
and emergency (A&E) patients’ risk of falling by observing the patient or by filling in a paper
based form rather than by filling in a computer-based version of the Morse fall scale (Morse,
1997) as used in the other departments of the hospital, given the unpredictability and urgent
character of the activities of the A&E unit and its IT systems.
The adoption of a collaborative approach not only resulted in the design of contextualised
procedures and the consequent buy-in from staff, but also led to a shared quality
improvement culture where all staff felt welcomed to contribute to. This impact on culture is
particularly significant given its perceived importance on quality and patient safety
improvements. During interviews, culture was frequently mentioned as one of the factors that
contribute the most for differences in quality and patient safety across departments and
hospitals:
I think that what leads to differences [in quality] between hospitals and between
[hospital] departments is people’s sensibility [to quality issues] or realizing that [some
actions] can make a difference (Nurse).
A final example of contextualisation was the developmental way in which the hospital used
performance management systems. Although as part of the accreditation process the hospital
started to give a greater emphasis on statistics and performance monitoring, these were used
as information and learning tools rather than a means towards formal accountability and/or in
a punitive way. This constructive approach led to a high staff motivation to contribute to
quality improvement. An example of this culture was portrayed in how staff approached
incidents notification:
Reporting incidents can be done in an anonymous way. Curiously, in more than 2000
incident reports only 40 are anonymous. Thus there is no fear of reporting (Member
of the quality management department).
Page 14 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
15
Alongside the autonomy to manage the accreditation process, which facilitated a high degree
of contextualisation with the advantages discussed above, another critical factor for the
positive results of the accreditation was the commitment of the hospital board. As described
in the following quotes, this commitment ensured the allocation of appropriate resources and
facilitated organisational change:
The involvement of top management was fantastic because there are cross-
departmental changes that couldn’t have been accomplished without the involvement
of top management because it involves costs, involves time, involves human
resources and all of this needs to be paid (Nurse).
Patient safety and clinical risk need to be a strategic priority of the organisation […]
otherwise there is no chance to work on the ground, as we did […] we improved
clinical auditing and we trained staff and it was expensive because it is a very high
financial investment. I think we were lucky in having a president of the board that was
a clinician and realised that the price of bad quality was very high and thus invested in
training and clinical auditing (Member of the quality management department).
Finally, another hospital feature that facilitated quality improvement through the
accreditation process was the baseline level of quality development in the hospital. At the
time the hospital embarked on the accreditation process many of the required procedures
were already in place, albeit in some cases informally. This facilitated the achievement of the
accreditation requirements:
Many clinical units already had written procedures for a long time (Member of the
quality management department).
[With the accreditation] we created clinical auditing. In some cases it was a matter of
formalising what already existed […] a lot of work was already done but it wasn’t
written down and wasn’t systematised. [For example], the result [of the audit] would
stay there without the follow-up [we now have] (Member of the quality management
department).
Discussion
A central finding from this study is hospital’s staff perception that accreditation can
contribute to significant improvements in quality and patient safety but that attaining these is
strongly dependent on how accreditation is implemented in practice and the characteristics of
Page 15 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
16
the hospital setting. Interviewees reported that accreditation led to a higher concern with
patient safety as an aspect of healthcare quality which resulted in significant quality and
patient safety improvements, including the establishment of a generalized patient safety
culture. These observations are in line with studies conducted by Hosford (2008) who
recognised accreditation as an effective intervention to drive patient safety improvements and
by Longo et al. (2007) who identified accreditation as the key predictor of the
implementation of patient safety systems. The findings are also consistent with previous
studies that reported that over time accredited hospitals significantly saw greater progress on
quality (Schmaltz et al., 2011) and patient safety systems (Longo et al., 2007) than non-
accredited hospitals.
During interviews, respondents identified a series of other intrinsic characteristics of the
accreditation which fostered quality improvements. First and foremost, the fact that
accreditation requires meeting a set of norms by a specific date provided a powerful tool to
finally introduce long-awaited changes as it overcame the resistance to introduce them. This
feature of accreditation has been pointed out by previous research that has acknowledged
accreditation as an “effective leitmotiv for the introduction of change” (Pomey et al., 2010:1).
As Duckett (1983:1574) identified, one of the most striking features of accreditation is its
usefulness as a weapon to “be used for the completion of various tasks which are overlooked
in the ‘routine burly-burly of shifting paper’”. Furthermore, in the case study hospital,
accreditation provided an opportunity for reflection on the existing practices and fostered the
formalisation of procedures, which confirms the findings of other studies (Pomey et al., 2004;
Pomey et al., 2010). As Pomey et al. (2004) found in their study of a university hospital, the
formalisation of practices also led to a change from a hospital where organisational learning
was mostly transmitted by word of mouth to a hospital where learning is significantly
supported by a writing culture.
In the interviewees’ views, alongside the characteristics of the accreditation process, several
factors associated with the hospital and how the accreditation was implemented significantly
impacted on the quality and patient safety improvements attained through accreditation. From
the outset, the hospital board’s commitment to the accreditation process, including the
facilitation of appropriate financial and personnel resources were frequently mentioned
during interviews as an important facilitator of quality and patient safety improvements. The
institutional commitment to improve quality and patient safety and the availability of
resources have been identified by patient safety studies as key facilitators of patient safety
improvements (Devers et al., 2004; Fukuda et al., 2009). Findings from the case study also
Page 16 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
17
reinforce the importance of a strong leadership in achieving better outcomes from
accreditation which has been pointed out by authors such as Braithwaite et al. (2010).
Another key reason of the hospital’s accreditation outcomes relates with how the
accreditation was implemented. The case study hospital was given the autonomy to choose to
embark or not on the accreditation process and was allowed to manage its accreditation
process with independence. For the case study hospital, this high autonomy led to the
possibility of adjusting the accreditation standards to the hospital’s context, which resulted in
a high acceptance of the accreditation procedures and positive outcomes in terms of quality
and patient safety improvements. During interviews it was clear that implementing the
accreditation following a collaborative approach which welcomed staff’s participation and
sharing of their views was a key success factor of the positive outcomes of the accreditation
process. Adopting an accreditation program following a collaborative ethos has been
identified by Hinchcliff et al. (2013) as a critical enabler in the effective implementation of
an accreditation program.
Furthermore, in the case study hospital, the knowledge of the activities of clinical
departments and of the specificities of its patients, alongside the ability of the case study
hospital to tailor patient safety initiatives to each clinical unit’s context were pointed out by
interviewees as fundamental aspects in the design and implementation of effective patient
safety initiatives. In Devers’s et al. (2004) study of US hospitals, the existence of managers
and clinicians with knowledge about suitable patient safety solutions and ways to implement
them according to the hospital’s context was also perceived as a valuable institutional
nonfinancial resource.
Albeit patient safety literature recognises the knowledge of and capacity to adapt to the
context as two important factors towards the successful implementation of patient safety
initiatives, it often considers the importance of contextualisation at an organisational level
rather than contextualisation according to the specificities of individual departments or
clinical units. In the case study hospital, concerns with the contextualisation at a micro level
assumed high significance. As seen above, in the case study, the peculiarities of the clinical
departments were taken into account during the design of patient safety initiatives (e.g. re-
design of the falls reporting form to fit the clinical condition of the maternity unit patients)
and at the implementation stage (e.g. use of observation or a paper-based version of the
Morse fall scale in the A&E, instead of the computer-based version used in the other hospital
departments). This capacity to adapt procedures at departmental level to fit with the IT
Page 17 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
18
systems of the A&E also allowed overcoming the limitations of the IT infrastructure which
are recognised as a common hospital structural barrier in the implementation of IT- intensive
patient safety initiatives (Devers et al., 2004).
The importance of autonomy and contextualisation is in line with Touati and Pomey’s (2009)
study on French hospitals where the authors concluded that the fact that the accreditation
process was compulsory and hospitals were required to fulfill certain standards by law
resulted in the accreditation process being perceived as an inspection. Additionally, the
impossibility of adapting the accreditation standards to the context of specific clinical
departments led to criticisms regarding the legitimacy of such standards (Touati and Pomey,
2009).
Two other internal hospital features mentioned by interviewees as very important for the
maximisation of the impact of accreditation on quality and patient safety improvements were
the quality management department and the hospital’s previous experience with quality
improvement initiatives. The concentration of all quality management activities, including the
accreditation process, in a single department dedicated to quality management and which
hierarchically is comparable to the other hospital departments was perceived by interviewees
as a facilitator of the accreditation positive outcomes on quality and patient safety. The
quality management department was seen as a mechanism to enhance the coordination of
hospital’s quality activities, including knowledge sharing across the hospital departments.
Additionally, the concentration of all quality projects in a relatively small department also
fosters the possibility of attaining greater economies of scale in the use of resources. This
finding is in consonance with Fukuda et al.’s (2009) study of Japanese hospitals, where the
authors found that from an economic perspective, it is easier for bigger hospitals to
implement patient safety initiatives, given that the economic burden is significantly larger for
smaller hospitals.
Given that the accreditation process requires demonstrating that the institution meets the
accreditation norms, a greater experience on quality initiatives fosters an institution’s
potential of learning with the accreditation process, therefore maximising the propensity to
achieve even greater quality improvement outcomes. The years involved in quality
improvement initiatives have been pointed out in the literature as an important factor for the
success of such projects (Kaplan et al., 2010). Similarly, the readiness for change and
easiness in adopting the required procedures contribute to the achievement of greater impacts
through accreditation (Duckett, 1983). The fact that in the case study hospital many of the
Page 18 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
19
procedures required by the accreditation already existed in practice, albeit informally, was
perceived by interviewees as facilitating the hospital in meeting the accreditation norms. In
several cases meeting these standards essentially required writing the existing procedures.
Additionally, given that the hospital was already significantly advanced in terms of quality
improvement practices, the accreditation process fostered the hospital to use it to improve
even further its existing procedures. Finally, the large number of staff in the case study
hospital and the fact that the hospital is a teaching hospital facilitated the quality management
department’s access to a larger body of knowledge when compared with that generally
available to a smaller hospital.
Conclusion
One of the key conclusions of this study is that although the accreditation process itself has
features that can foster quality improvement, the achievement of such improvements is
strongly conditioned by the hospital’s baseline level of quality as well as the quality
management and patient safety activities that exist at the time the hospital embarks on
accreditation. Given the significant impact that hospital’s characteristics have on the
outcomes of accreditation, findings from the case study seem to point out that differences
among the hospitals that have embarked on accreditation processes are one of the main
reasons why accreditation processes have resulted in disparate outcomes.
Whereas this study provides important findings, it also has limitations because of the
characteristics of qualitative research in general, and of the research methods employed.
Given the single case study method adopted, the generalizability of the findings to other
settings has limitations (Yin, 2013). Also, the very fact that the study depended on
interviewees to gather most of the data conditioned the researcher’s knowledge of the case
study. As Rossman and Rallis (2003:124) note, “[i]nterviewing takes you into participants’
worlds, at least as far as they can (or choose to) verbally relate what is in their minds.”
Additionally, the present study drew significantly on the opinion of hospital staff directly
involved in the design and implementation of quality and patient safety initiatives, with the
majority of interviewees being nurses. This fact could have resulted in a bias from clinicians
in general, and from the nursing profession in particular. Finally, interviews were conducted
and analyzed by the author. As a feature of qualitative research, the key role of the researcher
in the whole research process could have influenced the quality of the evidence gathered and
the interpretation of the data.
Page 19 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
20
Research on hospital accreditation would benefit from additional research on the
implementation process in order to identify other factors that potentially impact on the
outcomes of accreditation in terms of quality and patient safety improvements. A suggestion
for further research would be to conduct other in-depth case studies in different hospital
settings. For example, non-teaching hospitals, hospitals of smaller size, for-profit hospitals,
and hospitals belonging to health systems with mandatory accreditation programs.
Additionally, further research could investigate the impact of accreditation on hospital
performance using quantitative methods alongside qualitative methods. Comparing the
findings of this study with those of future studies would allow assessing the extent to which
the findings were influenced by methodological limitations.
References
Agius, S. J., Brockbank, A., Baron, R., Farook, S., and Hayden, J. (2015), “The impact of an
integrated medical leadership programme”, Journal of Health Organization and
Management, Vol. 29 No. 1, pp. 39-54.
Black, T. R. (2002), Understanding social science research, Sage Publications, London.
Boaden, R. (2005), “The contribution of quality management to patient safety”, Walshe, K.
and Boaden, R., Patient safety: research into practice, Open University Press,
Maidenhead, pp. 41-65.
Bogh, S. B., Falstie-Jensen, A. M., Bartels, P., Hollnagel, E., and Johnsen, S. P. (2015),
“Accreditation and improvement in process quality of care: a nationwide study”,
International Journal for Quality in Health Care, Vol. 27 No. 5, pp. 336-343.
Braithwaite,J., Greenfield,D., Westbrook,J., Pawsey,M., Westbrook,M., Gibberd,R.,
Naylor,J., Nathan,S., Robinson,M., Runciman,B., Jackson,M., Travaglia,J., Johnston,B.,
Yen,D., McDonald,H., Low,L., Redman,S., Johnson,B., Corbett,A., Hennessy,D.,
Clark,J., Lancaster,J., (2010), “Health service accreditation as a predictor of clinical and
organisational performance: a blinded, random, stratified study”, Quality & Safety in
Health Care, Vol 19 No. 1, pp. 14-21.
Chassin, M. R. (2013), ”Improving the quality of health care: what's taking so long?”, Health
Affairs, Vol. 32 No.10, pp. 1761-1765.
Page 20 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
21
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.
DelliFraine, J. L., Langabeer, J. R., and Nembhard, I. M. (2010), “Assessing the evidence of
six sigma and lean in the health care industry”, Quality Management in Health Care,
Vol. 19 No. 3, pp. 211-225.
Devers, K. J., Pham, H. H., and Liu, G. (2004), “What is driving hospitals' patient-safety
efforts?”, Health Affairs, Vol. 23 No.2, pp. 103-115.
Diab, S. M. (2011), “The extent to which Jordanian doctors and nurses perceive the
accreditation in private hospitals”, International Journal of Marketing Studies, Vol. 3
No.1, pp. 78-94.
Duckett, S. J. (1983), “Changing hospitals: the role of hospital accreditation”, Social Science
and Medicine, Vol. 17 No. 20, pp. 1573-1579.
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.
Fukuda, H., Imanaka, Y., Hirose, M., and Hayashida, K. (2009), “Factors associated with
system-level activities for patient safety and infection control”, Health Policy, Vol. 89
No.1, pp.26-36.
George, A. L., and Bennett, A. (2005), Case studies and theory development in the social
sciences, MIT Press, Cambridge, Massachusetts.
Graham, N.O. (1995), “Quality trends in health care”, Graham, N.O., Quality in health care:
theory, application and evolution, Aspen Publishers, Inc, Maryland, pp. 3-14.
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., Pawsey, M., Hinchcliff, R., Moldovan, M., and Braithwaite, J. (2012), “The
standard of healthcare accreditation standards: a review of empirical research
underpinning their development and impact”, BMC Health Services Research, Vol. 12,
pp.329
Hadley, T. R., & McGurrin, M. C. (1988), “Accreditation, certffication, and the quality of
care in state hospitals”, Psychiatric Services, Vol. 39 No. 7, pp. 739-742.
Page 21 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
22
Hammersley, M. (2001), What's wrong with ethnography?: Methodological explorations.
Routledge, London.
Hinchcliff, R., Greenfield, D., Moldovan, M., Westbrook, J. I., Pawsey, M., Mumford, V.,
and Braithwaite, J. (2012), “Narrative synthesis of health service accreditation
literature”, BMJ Quality & Safety, Vol. 21 No.12, pp. 979-991.
Hinchcliff, R., Greenfield, D., Westbrook, J. I., Pawsey, M., Mumford, V., and Braithwaite,
J. (2013), “Stakeholder perspectives on implementing accreditation programs: a
qualitative study of enabling factors”, BMC Health Services Research, Vol.13, pp. 437
Hosford, S. B. (2008), “Hospital progress in reducing error: the impact of external
interventions”, Hospital Topics, Vol. 86 No. 1, pp. 9-20.
Jaafaripooyan, E. (2011), Contextual approach to the performance analysis of Iran’s national
accreditation programme for healthcare organisations, Unpublished PhD Thesis,
University of Southampton, School of Management, Southampton.
Kaplan, H. C., Brady, P. W., Dritz, M. C., Hooper, D. K., Linam, W., Froehle, C. M., and
Margolis, P. (2010), “The influence of context on quality improvement success in health
care: a systematic review of the literature”, Milbank Quarterly, Vol. 88 No.4, pp. 500-
559.
Kilo, C. M. (1998), “A framework for collaborative improvement: lessons from the institute
for healthcare improvement's breakthrough series”, Quality Management in Healthcare,
Vol. 6 No.4, pp. 1-14.
Kohn, L. T., Corrigan, J., and Donaldson, M. S. (2000), To err is human: building a safer
health system, National Academy Press, Washington, D.C.
Longo, D. R., Hewett, J. E., Ge, B., Schubert, S., and Kiely, R. G. (2007), “Hospital patient
safety: characteristics of best-performing hospitals”, Journal of Healthcare
Management, Vol. 52 No.3, pp. 188-204.
Lutfiyya, M. N., Sikka, A., Mehta, S., and Lipsky, M. S. (2009), “Comparison of US
accredited and non-accredited rural critical access hospitals”, International Journal for
Quality in Health Care, Vol. 21 No. 2, pp. 112-118.
Maxwell, J. A. (2012), Qualitative research design: an interactive approach, 3rd ed., Sage,
London.
Page 22 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
23
McLaughlin, C. P., and Kaluzny, A. D. (2004), Continuous quality improvement in health
care: Theory, implementation, and applications, 2 nd ed., Jones and Bartlett Learning,
Sudbury.
Miller, M. R., Pronovost, P., Donithan, M., Zeger, S., Zhan, C., Morlock, L., and Meyer, G.
S. (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.
Morse, J. M. (1997), Preventing patient falls, Sage Publications, Thousand Oaks, Calif.
Morris, S. (2001), “Joint and individual interviewing in the context of cancer”, Qualitative
Health Research, Vol. 11 No. 4, pp. 553-567.
Polak, L. and Green, J. (2016), Using joint interviews to add analytic value, Qualitative
Health Research, Vol. 26 No. 12, pp. 1638-1648
Pomey, M., Contandriopoulos, A., François, P., and Bertrand, D. (2004), “Accreditation: a
tool for organizational change in hospitals?”, International Journal of Health Care
Quality Assurance, Vol. 17 No. 3, pp. 113-124.
Pomey, M., Lemieux-Charles, L., Champagne, F., Angus, D., Shabah, A., and
Contandriopoulos, A. (2010), “Does accreditation stimulate change? a study of the
impact of the accreditation process on Canadian healthcare organizations”,
Implementation Science, Vol. 5 Article No.31
Ribeiro, J. M. (2004), “Reforma do sector público hospitalar: Programa de empresarialização
de 34 hospitais portugueses”, Revista Portuguesa de Saúde Pública, Vol. 4, pp. 65-77.
Rooney, A. L., and Van Ostenberg, P. R. (1999), Licensure, accreditation, and certification:
Approaches to health services quality, Quality Assurance Project, USAID, Bethesda,
MD.
Rossman, G. B. and Rallis, S. F. (2003), Learning in the field: an introduction to qualitative
research, Sage Publications, Thousand Oaks, Calif.; London.
Saleh, S. S., Bou Sleiman, J., Dagher, D., Sbeit, H., and Natafgi, N. (2013), “Accreditation of
hospitals in Lebanon: is it a worthy investment?”, International Journal for Quality in
Health Care, Vol. 25 No. 3, pp. 1-7.
Page 23 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
24
Salmon, J. W., Heavens, J., Lombard, C., and Tavrow, P. (2003), The impact of accreditation
on the quality of hospital care: KwaZulu-Natal province Republic of South Africa,
Quality Assurance Project, USAID, University Research Co., Bethesda: MD
Schmaltz, S. P., Williams, S. C., Chassin, M. R., Loeb, J. M., and Wachter, R. M. (2011),
“Hospital performance trends on national quality measures and the association with joint
commission accreditation”, Journal of Hospital Medicine, Vol. 6 No.8, pp. 454-461.
Schouten, L. M., Hulscher, M. E., van Everdingen, J. J., Huijsman, R., and Grol, R. P.
(2008), “Evidence for the impact of quality improvement collaboratives: systematic
review”, British Medical Journal, Vol. 336 No.7659, pp. 1491-1494.
Shaw, C., Groene, O., Mora, N., and Sunol, R. (2010), “Accreditation and ISO certification:
do they explain differences in quality management in European hospitals?”,
International Journal for Quality in Health Care, Vol.22 No. 6, pp. 445-451.
Spencer, L., Ritchie, J., Ormston, R., O' Connor, W., and Barnard, M. (2014), “Analysis:
principles and processes”, Ritchie, J., Lewis, J., Nicholls, C.M. and Ormston, R.,
Qualitative research practice: a guide for social science students and researchers, 2 nd
ed., Sage, London, pp. 269-293.
Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., and Reed, J. E. (2014),
“Systematic review of the application of the plan-do-study-act method to improve
quality in healthcare”, BMJ Quality & Safety, Vol. 23 No. 4, pp. 290-298.
Thor, J., Lundberg, J., Ask, J., Olsson, J., Carli, C., Härenstam, K. P., and Brommels, M.
(2007), “Application of statistical process control in healthcare improvement: Systematic
review”, Quality and Safety in Health Care, Vol. 16 No.5, pp. 387-399.
Thornlow, D. K., and Merwin, E. (2009), “Managing to improve quality: the relationship
between accreditation standards, safety practices, and patient outcomes”, Health Care
Management Review, Vol. 34 No. 3, pp. 262-272.
Touati, N., and Pomey, M. (2009), “Accreditation at a crossroads: are we on the right track?”,
Health Policy, Vol. 90 No. 2, pp.156-165.
Vincent, C. (2011), Patient safety, 2 nd ed., John Wiley & Sons, Chichester.
World Health Organisation. (2003), Quality and accreditation in health care services: a
global review, Department of Health Service Provision, Geneva.
Page 24 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
25
Yin, R.K. (2013), Case study research: design and methods, Sage, Thousand Oaks,
California.
Page 25 of 26 Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Journal of H ealth O
rganization and M anagem
ent
9. Permissions checklist
Please note that Emerald requires you to clear permission to re-use any material not created by you. Emerald is unable to publish your paper with permissions outstanding.
Please ensure you have done the following: (please tick C)
Cleared permission to use any material (including content freely available on the web) not authored by you. This applies to tables/illustrations/figures/photographs and excerpts of more than 400 words. Please attach evidence to this form.
V
Included full references for all tables/illustrations/figures/excerpts. (Please refer to the Author Guidelines for advice on correct acknowledgement).
V
Cleared permission with the copyright holder, if any adaptation is significantly similar to the original material
V
Cleared permission with any company if you have included a photograph of a logo or product.
V
Cleared permission with the creator(s) of any photograph(s), if not taken by you. V
Where possible, cleared permission with the subject(s) of any photograph(s). V
Cleared permission to use any material authored by you, if you have assigned copyright to another party.
V
Emerald is a member of the STM Association and participates in the reciprocal free exchange of material with other STM members. This may mean that in some cases, authors do not need to clear permission for re-use of content. Authors should check the STM website to find participating publishers and follow STM’s permissions guidelines. See: http://www.stm- assoc.org/copyright_and_legal_permissions_guidelines.php
Page 26 of 26Journal of Health Organization and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
