International Journal of Health Care Quality Assurance

Accreditation in one teaching hospital: a phenomenology study among Iranian nurses

Mohammadkarim Bahadori,
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 Accreditation in one teaching hospital: a phenomenology study among Iranian nurses

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
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Author 4: Ramin Ravangard, Health Services Management, Assistant Professor, Department of

Health Services Management, Shiraz University of Medical Sciences, Shiraz, Iran,
Telephone: +98712340039, E-mail: ra_ravangard@yahoo.com
Author 5: Khalil Alimohammadzadeh, Health Services Management Associate Professor,
Health Services Management Department, North Tehran Branch, Islamic Azad
University, Tehran, Iran, Telephone: +982122977862, E-mail:
dr_khalil_amz@yahoo.com
Author 6: Seyed Mojtaba Hosseini, Health Services Management, Assistant Professor, Health
Services Management Department, North Tehran Branch, Islamic Azad University,
Tehran, Iran, Telephone: +982122977862, E-mail: dr_hosseini82@yahoo.com

Corresponding author: Mohammadkarim Bahadori

Corresponding Author’s E-mail: bahadorihealth@gmail.com

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.

Keywords: Accreditation, Healthcare, Hospital quality, Iran.

Article Classification: Research Paper

Received – August 8th, 2017

Revised – Oct 19th, 2017
Accepted – Dec 16th, 2017

Introduction
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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:
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1. Accreditation and its meaning for nurses.

2. Service quality improvements.
3. Occupational group roles when implementing the accreditation program.
4. Human resource management in the accreditation process.
5. Using information for planning and quality improvement.

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.

What accreditation means for nurses

Nurses believed that accreditation aimed to improve hospital service quality and safety. Being
patient-centered and raising patient satisfaction were the other topics mentioned by nurses. Some
nurses pointed out that accreditation was only paperwork and a bureaucratic process, and
increased stress on employees (Table I).

In my opinion, accreditation is just paperwork and a bureaucratic process, and is only

documentation (Participant 1)

… accreditation in my mind is equal to the high stress and the large volume of
documentation!! (Participant 4)

Table I here

Service quality improvement

 Paying more attention to patients, improving clinical processes and safety, improving support,
logistics and managerial processes were topics related to quality improvement experienced
personally by nurses after accreditation was implemented. One nurse stated that:

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)
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Table II here

Occupational group roles in implementing the accreditation program

Focus group participants believed that nurses had the most important role in implementing
accreditation standards. Also, senior managers’ active role was important from the nurses'
viewpoints. One participants said:

... 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)

Human resource management

Nurses believed that there was no appropriate hospital incentive system. Despite improved
empowerment in the hospital, nurses believed that stresses caused by some human resource
management processes and the discrimination in the financial payments had decreased employee
motivation. However, one nurse noted:

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)

Table III here

Using information for planning and quality improvement

 Using information for improving clinical and economic performance were two topics
experienced by the nurses during the hospital accreditation program. Developing quality
improvement programs in the hospital wards and units by monitoring data periodically was a
topic mentioned by a head nurse.

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
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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
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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).

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Table I: Accreditation: nurses’ perspectives

No. Themes Sub-themes

1
Poor attention to the staff Stress on staff
2
Staff neglect
3
Being patient-centered Paying attention to patients
4
Respecting patients
5
Patient satisfaction
6
Superfluous documentation Paperwork and a bureaucratic process
7
Wasting time on documentation
8
Documentation volume
9
Improving quality and safety Improving patient safety
10
Improving the quality and safety
11
Other Updated information
 12
Changes
13
Assessing compliance with standards

Table II: Service quality improvement: nurses' perspectives.

No. Themes Sub-themes

1
Being more patient-centered Obtaining informed consent
2
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Observing patient rights

3
Respecting patient privacy
4
Patients' independence in choosing a physician
5
Improving patient education (admission,
discharge and during service delivery)
6
Promoting patient safety Reducing medical errors
7
Reducing surgery errors
8
Reducing medication errors
9
Improving patients' identification
10
Reducing nosocomial infections
11
Observing hand hygiene standards
12
Empowering employees Improving employee education
13
Improving education for new employees at the
outset
14
Improving logistic processes Improving medical equipment maintenance
and upkeep
15
Reducing occupational hazards
16
Improving medical waste disposal
 17
Improving kitchens
18
Paying attention to Information Technology
(IT) processes
19
Improving the collaboration among units and
wards
20
Improving residential services for patients and
their companions
21
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Improving service effectiveness Registering and recording nursing notes and

reports
22
Drug combinations
23
Improving managerial processes Improving teamwork
24
Changing employee attitudes
25
Increasing senior manager commitment
26
Risk managing via FMEA-RCA*
*: Failure Mode and Effects Analysis (FMEA)-Root Cause analysis (RCA)

Table III: Human resource management: nurses' perspectives

No. Themes Sub-themes

1
Incentive system Low employee motivation
2
Discrimination in financial incentives
3
Inappropriate reward and encouragement
system
4
Punitive system for employees
5
Improving moral support
6
Improving amenities and immaterial benefits
for employees
 7
Weaknesses in employees' Work stress
8 retention
Good recruitment, but poor retention
9
Clarifying human resource Promoting the cooperation using human
management processes resource management
10
Clarifying payments to employees

Table IV: Using information for planning and quality improvement: nurses' perspectives
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No. Themes Sub-themes

1
Using statistics for improving Lowering phlebitis rates using monthly statistics and
clinical practices quality improvement program
2
Staffing operating room according to the operating
room performance statistics
3
Providing feedback to physicians to reduce caesarean
section rates
4
Using statistics for improving Assessing and evaluating hand hygiene and
safety performing interventions based on results
5
Using statistics for improving Developing an economic productivity system based on
economic performance ward performance statistics
6
Signing contracts with medical insurance companies to
increase service delivery
7
Using wards statistics and involving wards heads in
budgeting
8
Considering the customer’s voice Measuring patient and employee satisfaction and
carrying out interventions based on results
9
Monitoring complaints and taking interventional
measures