The impact of accreditation on quality of care in accredited public hospitals in Saudi Arabia: a mixed methods study

This thesis examined the impact of accreditation on quality of care in three accredited public hospitals in Saudi Arabia. More specifically, this thesis investigated the relationship between quality processes and quality outcomes. In addition, the association between accreditation and quality indicators was investigated. At the same time, this thesis explored the perceptions of health practitioners and senior managers about accreditation. Analysis of the research literature revealed that the impact of accreditation on quality of care had not been investigated in any systematic way. Accreditation is one of the most important tools for quality improvement in healthcare organisations. It is a means by which health services are assessed externally to determine whether they comply with international standards. Saudi Arabia has only recently implemented accreditation processes to improve healthcare programs. In 2005, the Central Board for Accreditation of Healthcare Institutions (CBAHI) was established following the recommendations of the Council of Health Services (Saudi Arabia). The CBAHI was formed to develop and implement quality standards in all health organisations in Saudi Arabia to improve health services. The impact of accreditation on public hospitals in Saudi Arabia is an important issue for those demanding improvements in the quality of care delivered in this system. Analysis of the literature revealed that although accreditation has been used in many countries to review and improve quality of care, there is a lack of evidence to show whether accreditation programs are effective. In addition, no study in Saudi Arabia has been conducted to examine the impact of CBAHI accreditation on quality of care. The conceptual framework underpinning this thesis was drawn from the Donabedian model (1980). Most previous studies have used quantitative methods (survey) only. It was argued that this presented particular difficulties because of the pivotal roles of qualitative methods and documentary statistical analysis. Therefore, it was decided that a mixed methods approach would provide a comprehensive picture of this important issue. A mixed methods approach was utilised in this thesis by conducting three studies. Study 1 was a survey of quality of care and accreditation by health practitioners. A total of 669 questionnaires were returned, giving a response rate of 68.8% and 163 answers to the open-ended questions. The data were subjected first to simple descriptive statistical analysis. This analysis revealed that most of the respondents were female (526, 78.6%), half of them (332, 49.6%) below 30 years and 554 (82.8%) were non-Saudi. A total of 286 respondents (42.8%) had been working for 3-5 years, more than half of the respondents (368 people or 55%) had a Bachelor degree. A total of 504 (75.3%) respondents were nurses and 81 (12.1%) were physicians. The vast majority of the respondents (620, 92.7%) were at employee level and 512 (76.5%) of them had experience of accreditation processes. The results showed a value of 0.968 for the survey which is reasonable, indicating the tool’s internal consistency, which suggests its suitability for the study. The nationality of the health practitioners who responded had a significant influence on their perceptions of quality of care and accreditation. The results indicated that non-Saudis reported slightly higher scores for quality of care and accreditation than Saudi nationals. This might be explained by the fact that the Saudi health practitioners were not as concerned about losing their positions compared to professionals from different backgrounds. Correlation analysis indicated a positive correlation between quality process sub-scales and quality results and between quality process sub-scales and accreditation results. The correlation between operational focus and quality results was the strongest (γ = .645, p< .000), and the correlation between professional participation and quality results was the lowest (γ = .421, p< .000). The correlation between the benefits of accreditation and accreditation results was the strongest (γ = .547, p< .000), and the correlation between professional participation and accreditation results was the lowest (γ = .347, p< .000). The stepwise regression model indicated that operational focus is the most predicted variable and this variable explained 41% of the variation in quality results. In addition, the stepwise regression model indicated that the benefit of accreditation is the most predicted variable and this variable explained 30% of the variation in accreditation results. The results of this study are consistent with a study by Yildiz and Kaya (2014), who found that the benefit of accreditation was the most predictable quality outcome variable. The results of the open-ended questions were analysed using thematic analysis. Six main themes emerged from the open-ended questions: i: accreditation was too focussed on paperwork, ii. there were no monitoring programs after the completion of the accreditation process, iii. there were manpower shortages during the process, iv. there was a lack of staff involvement, v. there was a lack of training after accreditation, vi. hospital management unfulfilled promises post-accreditation. Study 2 in this thesis involved a documentary statistical analysis of quality indicators from existing Ministry of Health reports. These indicators included mortality, infection and length of stay. A pre-test/post-test design was used, in which quality indicators were taken both before and after accreditation. Quality indicators were collected for the period of 2009-2013. Odds ratios (ORs) were used to measure the association between accreditation and quality indicators. The results of Study 2 showed no clear association between accreditation and the three indicators. In terms of mortality, the results indicated that there was no significant difference between the mortality rates before and after CBAHI accreditation in the three hospitals. In terms of infection, there were statistically significant differences at all three hospitals. The rates of infection varied among the three hospitals. For example, infection rates increased after CBAHI accreditation in Hospitals A and C, whereas in Hospital B, the infection rates decreased after accreditation. The results for length of stay were statistically significant for Hospital A and Hospital B. The length of stay at Hospital A was higher after accreditation than before it, whereas at Hospital B, the length of stay was lower after accreditation. The results of length of stay for Hospital C were not statistically significant. The length of stay for Hospital C before accreditation was similar to that after accreditation. The results of Study 2 are consistent with previous work by Braithwaite et al. (2010), who found inconsistent relationships between accreditation and quality indicators. Study 3 used semi-structured interviews with senior managers. 12 interviews were conducted with senior managers (hospital managers, medical managers, quality managers and nursing managers). The semi-structured interviews with senior managers were transcribed verbatim. These transcripts were then subjected to thematic coding procedures. The results of thematic analysis of the semi-structured interviews revealed a mixed picture. Although the interviewees acknowledged the benefits of accreditation, such as improved communication, patient satisfaction, reporting systems, workplace culture, and the implementation of an organisational mission and vision, they also criticized accreditation. Accreditation was criticized for being too focused on paper work, and failing to involve physicians. Other criticisms included manpower shortages during the process, a lack of staff involvement, an increased workload and an emphasis on structure over clinical practice; accreditation was also viewed as cross-sectional rather than focused on improvements over time. Senior managers suggested that community involvement, leadership support, training and reforming the workplace culture were important factors in improving quality of care and accreditation. The results of this thesis demonstrated that although some improvements in the procedures were recognised, CBAHI accreditation was not associated with better outcomes. These results are consistent with those of Merkow and colleagues (2014), who found that accredited centres performed well on most process measures but not on outcome measures. This thesis illustrated the need to sustain improvements over the accreditation cycle; this means meeting the immediate accreditation standards, as well as establishing a basis for ongoing quality improvement into the future. The characteristics of sustainable improvement over the accreditation cycle are discussed and analysed. Approaches to sustained improvement over the accreditation cycle include allowing organisations to voluntarily sign up to accreditation. Another approach is to shift the paradigm to unannounced surveys. A movement to modern accreditation which includes all three aspects of quality of care (structures, processes and outcomes) is important. Incorporating quality indicators into the accreditation standards process is another approach. Focusing on continuous quality improvement will also provide greater interest and engagement, resulting in a more sustainable outcome. For example, the Plan-Do-Study-Act method will lead to the development of a continual improvement cycle. In addition, leadership is viewed as one of the most important features in promoting sustainable accreditation and ongoing improvements. Engendering a quality culture in health organisations supports continuous quality improvement. Continuous training creates an awareness of quality within an organisation. Finally, physician involvement is one of the hallmarks of sustainable accreditation. In the concluding chapter, it was noted that the thesis had some strengths that are noteworthy. This thesis was the first research in Saudi Arabia to examine the impact of accreditation on quality of care. In addition, this research applied a mixed methods approach, which provides more extensive results and a holistic view of accreditation issues. The main strength of this approach is the combination of quantitative and qualitative data from three studies. The thesis concludes with a discussion of future research. It is suggested that future research could explore the relationship between CBAHI accreditation and quality indicators in more depth. It is also recommended to assess the impact of accreditation from patients’ perspectives and how they might discern improvement. In addition, a prospective longitudinal design might provide a more profound understanding of the change processes caused by CABHI accreditation in hospitals. Finally, it is recommended to study the phenomenon of implementing CBAHI accreditation from the perspectives of the CBAHI body and surveyors