International Journal for Quality in Health Care 2011; Volume 23, Number 6: pp. 645 –656 10.

1093/intqhc/mzr063
Advance Access Publication: 27 September 2011

Healthcare accreditation systems: further

perspectives on performance measures
EBRAHIM JAAFARIPOOYAN1,2, DILA AGRIZZI1 AND FAIZOLLAH AKBARI-HAGHIGHI2
1
School of Management, University of Southampton, Southampton, UK, and 2Department of Management Sciences and Health
Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
Address reprint requests to: Ebrahim Jaafaripooyan, School of Management, University of Southampton, Southampton, UK.
Tel: þ44-238059-5442; Fax: þ44-238059-3844; E-mail: e.jaafari@gmail.com

Accepted for publication 2 September 2011

Abstract

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Objective. The purpose of this paper is to identify and suggest a number of performance measures to facilitate the evaluation
of accreditation programs in healthcare.
Methods. The paper is based on an exploratory research which has used qualitative methods, including snowball sampling
technique, email interview and thematic content analysis.
Participants. Respondents (experts and professionals) were selected from a diverse spectrum ranging from healthcare organiz-
ations, universities and accreditation-associated institutions.
Results. The analysis of the data provided key measures to be considered in the evaluation of accreditation programs’ impact
at macro and micro levels as well as their nature and operations. The measures can be used to, for example, assess the degree
of stakeholders’ reliance on accreditation results, measure the cost of accreditation for participating organizations and serve as
a formal mechanism for accredited organizations to appeal accreditation decisions.
Conclusions. This paper has brought together a number of generic, yet influential and workable, measures which could be
utilized for assessing the overall performance of an accreditation program in healthcare. The application of these measures
depends on the features of given accreditation program and the context in which the program operates. Therefore, the next
step/steps in the assessment of an accreditation program might be choosing the measures suiting that program.
Keywords: performance measures, accreditation programs, performance measurement and improvement, healthcare

Introduction (i) The comprehensive and multidisciplinary nature of

It is argued that accreditation is one of the influential mech-
anisms for assessing the performance of healthcare organiz-
ations (HCOs) and improving the quality and safety of
healthcare services [1, 2]. Accreditation has been defined as
an external evaluation mechanism which assesses the per-
formance of HCOs through investigating their compliance
with a series of pre-defined, explicitly written standards
[3– 5]. Its aim is to encourage continuous improvement of
quality rather than simply maintaining minimal levels of per-
formance. It is also described as the public recognition ema-
nating from the achievement of specific standards by a HCO,
which is demonstrated after an independent external assess-
ment of the organization’s performance [6]. Specific features
of accreditation have presumably made this system more pre-
ferable for regulators, providers, third parties and customers
in healthcare, vis-à-vis other similar programs transposed
from industrial sector [7– 10]. These characteristics include
[8, 11, 12]:
the assessment.
(ii) The fit of the assessment method to the unique fea-
tures of healthcare.
(iii) Inclusion of improvement as a goal of the
assessment.
(iv) The use of highly trained surveyors with experience
in healthcare.
While accreditation programs are set up to evaluate HCOs,
their performance, as such, needs to be assessed to both
maintain their alignment with the initially determined objec-
tives and improve their merits and capabilities to continu-
ously detect the deficiencies and malpractices in HCOs [13,
14]. Critical outcomes [15] and information asymmetry
between providers and consumers in healthcare [16] have
added to the sensitivity and importance of these programs in
this area of the public sector. Their high cost for both those
running and being evaluated by accreditation programs has
augmented this importance [5, 17]. Despite this apparent

International Journal for Quality in Health Care vol. 23 no. 6

# The Author 2011. Published by Oxford University Press in association with the International Society for Quality in Health Care;
all rights reserved 645
Jaafaripooyan et al.
urgency, research into the effectiveness of these programs is
still at an embryonic stage [18, 19] and fewer studies than the
area deserves have embarked on an examination of their per-
formance [13, 20 – 22].
There is a lack of empirical evidence in the literature
exploring performance-related measures for assessment of
accreditation programs. Existing efforts have largely focused
on a single aspect of accreditation’s performance and impact
[cf. 18]. Accordingly, this paper seeks to provide valuable
insights in direct relation to the assessment of these evalua-
tory mechanisms, by suggesting a number of generic
measures for their evaluation. This is an important contri-
bution to the literature and practice for two main reasons.
First, the provided measures could facilitate the challenging
task of assessing accreditation programs’ performance [14,
23]. Some of the measures could also be used to support
the decisions by authorities and policymakers to gauge the
success of their programs in a specific period. Second, the
paper reflects the voice of groups (i.e. academics and pro-
fessionals), which have not been considered in this variety by
previous studies.
The paper is structured in the following fashion. The
first section provides a background on the related litera-
ture concerning the performance measurement of health-
care accreditation. The second section is devoted to
describing the research methods employed. The empirical
findings are presented in the next part, followed by dis-
cussion of the results.
Background
Previous research on the performance and impact of health-
care accreditation on HCOs has shown mixed and inconsist-
ent results [18, 19]. Existing literature abounds with various
studies showing either confirmatory [e.g. 24 – 27] or neutral
[e.g. 28 – 31] evidence regarding the effects of accreditation
programs on HCOs, with no consistent results. In their
extensive review of health sector accrediation research,
Greenfield and Braithwaite [18] could only find evidence for
capacity of these programs to promote change and pro-
fessional development in HCOs. Some studies on accredita-
tion have also been of limited support for its effectiveness,
due to their anecdotal nature or small-scale coverage [20].
Therefore, there has always been a call for more research to
investigate the effectiveness and performance of accreditation
programs [e.g. 14, 18, 20, 32 – 35].
The efforts to examine the impact of accreditation
program have assumed different forms in the literature.
Various aspects of accreditation have been discretely
addressed. For instance, Greenfield and Braithwaite [18] have
clustered the exsiting studies in terms of their focus on
accrediation. They found the cases in relation to accredita-
tion’s financial impact, consumers and professions’ attitudes
to accreditation, promoting change and professional develop-
ment and public disclosure by these systems. As such, Sunol
et al. [36, p. 27] have located the prior literature on the
impact of these programs in three distinct areas:
646
(i) The impact of accreditation on the quality and safety
of healthcare delivery.
(ii) The efficiency of accreditation tools and systems for
providing feedback with reliable information both to
the accreditation organizations as well as all key
stakeholders.
(iii) The impact on the capacity development of systems.
Braithwaite et al. [20] argue that only a multi-method, multi-
disciplinary, multi-level research design is capable of provid-
ing reliable evidence on the performance and impact of
accreditation. Scrivens’ approaches of ‘experience/perception
and objective indicator’ could provide a valuable lens to look
critically into and make sense of the current trends in study-
ing accreditation programs [37, p. 6]. The first approach
requires that the perceptions and experiences of various
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groups, involved in or related to accreditation (e.g. HCOs’
professionals and stakeholders) are elicited toward the differ-
ent aspects and functions of the program. Public sector
abounds with those studies adopting this approach; in the
healthcare [e.g. 38, 39] and the education sector [e.g. 40]. In
these studies, the perceptions of healthcare professionals and
accreditation surveyors have been solicited upon the per-
formance of their running accreditation system in terms of
accreditation standards, surveyors and implementation
processes.
The objective indicator approach, instead, calls for identify-
ing and developing tangible and intangible measures of
success (i.e. hospital performance indicators, patient satisfac-
tion, etc.) in connection with accreditation in HCOs. In line
with this approach, any change (e.g. in the quality of services)
in accredited HCOs is quantitatively investigated and the posi-
tive effects are attributed to the effective function and per-
formance of the accreditation programs. This approach
subsequently sees the changes as a confirmatory sign of the
programs’ impact on the organizations. The respective studies
include those, for instance, that sift through the relationship
between accreditation and clinical indicators [41, 42], patient
[43] or provider satisfaction [21] and the changes triggered by
these programs in subject organizations [e.g. 32, 44].
Both approaches have arguably their own strengths and
weaknesses. The perception approach has been criticized for
being superficial and judgmental [37]. Deficiency of the
objective approach lies mostly in the difficulty of measuring
performance in healthcare, such as long-lasting, multi-factor
and probable outcomes [45 – 47]. Øvretveit and Gustafson
[48] point to the methodological challenges in measuring
healthcare outcomes and conceiving causality between
accreditation and its possible outcomes. de Walcque et al. [5]
refer to possible disagreement of the programs’ stakeholders
on intended outcomes as a real cause of this challenge. As
such, Shaw [14, p. 455] has expressed concerns about the
difficulty of defining ‘endpoints’ of an accreditation program
and their change based on the expectations of users and
observers. Given these challenges, the results of different
studies that assume the objective indicator approach could be
prone to producing inconsistent and biased results. This
approach thus always carries concerns over its capability to

render a valid evaluation of accreditation programs’ perform-
ance in view of those challenges: just as Shaw [14] notifies of
the difficulty in evaluating these programs when compared
with clinical technology. Therefore, owing to the complex
nature of the health sector creating the foregoing challenges,
the perception approach might be considered safer from this
perspective, despite its deficiencies [37, 49]. A fairly wide
range of the current literature has utilized this approach as
mentioned earlier [e.g. 50, 51]. The most cautious, yet cred-
ible, outlook might be to synthesize two approaches.
Following from this debate and considering the mixed
results in the previous literature upon the performance and
impact of accreditation programs on HCOs, this paper casts
further light on the examination of these mechanisms in
healthcare. It aims to draw upon the ‘perceptions and experi-
ences’ of both experts and professionals to explore workable
guidelines for the assessment and improvement of these pro-
grams. The term ‘expert’ here is used for both academics
and practitioners, whose research or work is in a way related
to healthcare accreditation. ‘Professional’ refers to those
working inside HCOs.
Methods
This paper is based on an exploratory qualitative research
approach which has utilized both semi-structured interviews
and open-ended questionnaires in order to collect its related
data in a two-stage process [52]. For the first stage of the
research, a number of experts in healthcare accreditation
from a variety of universities (e.g. the USA and UK) and
healthcare accreditation-associated institutions such as Joint
Commission on Accreditation of Healthcare Organizations
(JCAHO), Australian Council on Healthcare Standards
(ACHS) and International Society for Quality (ISQua) were
interviewed. For the second stage, a group of hospitals’ pro-
fessionals in a developing country (i.e. Iran) was selected, in
order to introduce more practical and complementary views
on identification of accreditation programs’ measures. The
significance of professionals’ perspectives is highlighted by
Barker et al. [53], indicating that the mechanisms for judging
the delivery of a service must have the confidence of those
being evaluated.
To minimize bias related to country-specific variation in
accreditation programs, questions were designed to empha-
size definition and features common to most accreditation
programs (see Appendix) [5, 14, 37, 54].
Selection of respondents
A purposive sample, which is considered to be the most
common sampling technique for qualitative studies, was
used to select potential participants [55]. Inclusion criteria
for respondents at this stage were developed based on their
publications (i.e. mainly books and papers in the
accreditation-related refereed journals). Although there was
no asserted limitation and mandate for selecting the partici-
pants from a specific country, the intention was to consult
Evaluation of accreditation † Accreditation
the experts from those countries which have comparably
settled and successful accreditation systems (e.g. the USA,
Canada, Australia and France). A ‘snowball sampling’ tech-
nique was used at a later stage in order to identify
additional experts, in a way that at the end of the inter-
views, respondents were asked to nominate other people
who would be relevant for the purposes of the research
[56, p. 17]. Snowballing was helpful, because the nominator
was used as a form of reference to enhance the credibility
of this research. In addition, the new respondents were sup-
posed to be capable of answering the questions of the
research [56]. Overall, 35 experts were contacted, of whom
25 replied and consequently were interviewed by email
during 3 months starting from May 2008.
For the second stage, the senior managerial and clinical
members (i.e. hospital managers, matrons, supervisors and
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heads of Emergency Department, Laboratory, Radiology,
Medical Record and Pharmacy) of the provincial hospitals,
amounting to 150, were selected. The professionals’ famili-
arity with the accreditation was the underlying inclusion cri-
terion at this stage. The group was sent an open-ended
questionnaire asking their perspectives and comments on the
evaluation of accreditation programs. Of those contacted,
120 replied. The selection of the professionals from this
country was based on two main grounds: First, the country
has had a national accreditation program in place for a
number of years, meaning the professionals were familiar
with the overall concept of healthcare accreditation. The
second reason was the familiarity with and the ease of access
to the HCOs for the researchers. Moreover, the email inter-
view (method used for the first stage) was not easily appli-
cable to the professionals as it was with the other groups (i.e.
experts), given their time constraints and the different nature
of their work.
Data collection
Given the fact that experts were geographically located in
different parts of the world, conducting a conventional inter-
view could be highly expensive and time-consuming; thus the
‘email interview’ technique was adopted in this study.
The main reasons for selecting this particular technique
follow [57]:
(i) Potential participants were spread out in different
countries and not limited to a country or an organiz-
ation (as explained earlier).
(ii) Given time limitations, this method was convincingly
suitable, because they could respond in their own
time and without any pressure, which might have
positively reflected in the quality of their responses.
(iii) They all were supposed to have sufficient access to
the internet because of their position and job. This
was proved in the later stages of the research as the
majority of respondents replied to the emails.
The potential advantages of this technique have made it
highly capable for fulfilling the objectives of this study.
647
Jaafaripooyan et al.
Strengths such as being less costly, quick and more freedom
for respondents, could be further attribute to this technique
[see 57, p. 93]. However, operationalization of this technique
requires access to the internet by all respondents.
The experts were asked to answer the open-ended ques-
tions in the interview [52], drafted based on the review of
the relevant literature [e.g. 5, 6, 37] (see Appendix). They
were mainly directed at ascertaining ‘the measures, elements
and dimensions to be utilized for evaluating accreditation
programs in healthcare’. The purpose was to build up
general guidelines for assessing the performance of health-
care accreditation programs. The questions were also fol-
lowed by a statement asking for respondents’ other related
comments and leaving room for their suggestions to
improve the questions. Two follow-up emails were sent as
reminders to those respondents who did not respond within
the deadline. This raised the response rate significantly.
Further emails were exchanged in order to clarify any ambi-
guity seen in the responses.
In the case of professionals a self-administered question-
naire including similar questions, as in the previous stage,
was distributed by the researchers through mail among the
respondents. A phone reminder was also made for unre-
turned questionnaire after 2 weeks of initial distribution.
There was no tangible incentive anticipated for the respon-
dents, except that a copy of the results could be sent for
those interested. Overall, 120 questionnaires were returned.
It should be also mentioned that since the study did not
include the vulnerable groups as its respondents, the inter-
view protocol was only once reviewed by a number of aca-
demics for its validity, and not by any institutional review
board or human subjects research committee, before its
application to the empirical field.
Data analysis
Data analysis was conducted using Thematic Content
Analysis, which is a widely used methodology for analyzing
qualitative data [58]. It identifies and categorizes the recur-
ring themes that emerged from the data collection and, con-
sequently, reports the key elements addressed by the
respondents [59].
Drawing on this method, the data analysis was conducted
by the authors and comprised five distinct stages [56]. The
first stage (the preparation of data) consisted of collating the
information from the questionnaires and emails. During
the second phase (familiarity with data), the researchers
extensively reviewed and coded the content of data based on
their relevance to different aspects of accreditation programs.
At the next stage of the analysis (interpreting the data), the
similar codes were combined which formed a number of
general themes (e.g. cost of accreditation for HCOs). At this
stage, the codes were compared, refined and formulated into
the themes (i.e. measures). Such themes were then tested
against respondents at the final stage (verifying the data) in
an attempt to increase the validity of the results. Some of the
themes were removed and/or refined and polished, accord-
ing to respondents’ validation. At the final stage (representing
648
the data), three main groups of measures were achieved and
represented (see Tables 1– 3).
At the end of each stage, results were discussed and
agreed upon by the authors, in order to minimize the judg-
ment bias and maintain the consistency throughout the
analysis process. Adopting Thematic Content Analysis, the
researchers proceeded from categorizing and coding the data
to reflect on how the codes associate with each other,
leading to a more profound understanding of the issue.
Results
The findings of the study could be categorized under three
main headings based on the relevance of the emerged
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themes to the different aspects of accreditation programs.
(i) Societal impact.
(ii) Methodology (i.e. survey and standard).
(iii) Organizational impact.
These general concepts, elaborated in Tables 1 – 3, underline
a broad range of ‘highly specified, quantitative measures,
principles and guidelines’ in connection with the ‘perform-
ance measurement and improvement’ of accreditation pro-
grams in health sector. The tables both illustrate the
measures and provide an explanation as to their nature and
the way of their measurement, where required. The majority
of the measures put forth have a conceptual nature, yet very
few hard measures are also identified, such as surveyor train-
ing days and report turnaround time.
Discussion
The conceptual measures displayed in the tables are de facto
the result of synthesizing the perspectives of various
accreditation-concerned groups, geared to evaluating the
merits and worth of accreditation schemes in healthcare.
They are oriented toward a generic framework of accredita-
tion, irrespective of their voluntary/mandatory fashion.
However, those with obvious relevance to either of these
modes are also emphasized.
The underlying intention of the study is to identify general
measures for assessing the performance of the accreditation
programs. Therefore, its original focus is mostly on the
common grounds in the data gathered from the different
respondents. As such, the strictly context-related measures
(i.e. those highly associated with a specific accreditation pro-
grams, particularly in relation to the professionals’ views)
were removed from the indicators. The principal rationale for
considering and mixing the various groups’ perspectives is to
include the most possibly diverse range of relevant views on
the performance of the programs and render an integrated
assortment of the measures.
Some measures exclusively refer to accreditation programs’
nature and operations without carrying any positive/negative
value. For example, there is a debate about the virtue of ‘dis-
closing accreditation results to public’ in the literature [60].
 Evaluation of accreditation † Accreditation

Table 1 Societal (macro) impact of accreditation programs

Measure Explanation
.............................................................................................................................................................................

Uptake of accreditation programs by HCOs
Retention rate of HCOs by accreditation
programs
The level of community (i.e. HCOs) awareness of
accreditation programs
Reflection of local healthcare priorities in the
standards of accreditation programs
Representative governance structure for
accreditation programs
Demand for (voluntary) accreditation programs in the health sector,
in comparison with other external evaluation and improvement
initiatives such as ISO and EFQM
The rate of HCOs that have stayed returned or switched to a
(voluntary) accreditation program from ISO, EFQM, etc. during a
specific period because of its quality improvement merits
This might be an indicator of (voluntary) accreditation programs’
success and dominance in a society
This is important in the case of national programs, which they give
priority to the evaluation of locally delivered services
Representatives from different stakeholders, especially vulnerable
groups (e.g. patients) and third parties, in the programs’ governing

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structure (and surveying team). This could minimize the influence
of powerful stakeholders (e.g. states) in the evaluation process
Independence of accreditation programs An independent body for accreditation of HCOs which is not
influenced by powerful stakeholders such as states and evaluates
them based exclusively on their merits
A formal mechanism to appeal accreditation HCOs are formally allowed to appeal and receive a convincing
decision response in the event of complaints
Disclosure and clarity of accreditation results Accreditation programs communicate the ranking of HCOs to the
public which is discernible for the public
Cost of accreditation programs for HCOs All costs (e.g. application fee) of the programs for HCOs as
opposed to similar initiatives such as ISO
The degree of stakeholders’ reliance on † This could refer to the satisfaction of different stakeholders
accreditation results in their decision-making with the performance of the accreditation programs,
process validating the evaluation ranking made by these programs
† Stakeholders such as third-party organizations seek
accreditation ranking of HCOs to set their service contracts
with them
† Governments rely on this ranking to allocate resources to
HCOs
† Patients in those health systems with the ‘choose and book’
procedure might rely on the ranking of the hospitals to look
for their intended services
Transparency and consistency of accreditation † All stages and processes of accreditation programs are crystal
programs clear for HCOs (i.e. they know what they are asked by
accreditation programs) in a way that the HCOs are satisfied
with the transparency of all stages and requirements of
accreditation programs
† HCOs are informed of the changes in accreditation programs
regularly and in advance
Responsiveness and accountability of † Willingness (obligation) of accreditation programs to justify
accreditation programs their decisions about the performance of HCOs and take the
responsibility, if required
† Their intention and willingness to take into account the
capabilities and ‘out of hand’ problems of HCOs while
meeting the requirements of the programs
A reliable communication network Accreditation programs have a regularly updated website for
disseminating relevant information about their process and
standards for HCOs
Valuation of stakeholders’ feedback Systematic feedback from stakeholders concerning all stages of
accreditation is periodically sought

649
Jaafaripooyan et al.

Table 2 Methodology (survey and standards) of accreditation programs

Measure Explanation
.............................................................................................................................................................................

Trained, experienced and healthcare-
(hospital) oriented surveyors
Appraisal of surveyors’ performance
Surveyor replacement and turnover rate
Presence of HCOs’ members (as observers)
during surveyors’ evaluation
Ongoing monitoring of HCOs during the
intervening time between two accreditation
surveys
† The use of specifically tailored training programs for surveyors
† Regular examination of surveyors’ selection and training processes
A mechanism for regular appraisal of surveyors’ performance
This could reduce the risk of surveys turning into an informal and
routinized process and introduce fresh eyes to the process (low turnover
times might eliminate experience element)
This could both validate the assessment process and justify the results to
the members and create more clarification on HCOs’ activities to
surveyors
In light of long intervening times (e.g. three years), monitoring HCOs (via
announced and unannounced visits) during this time could keep HCOs
loyal to the requirements of (mandatory) accreditation programs and safe

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for patients
Cross-check of the survey report with HCOs This might increase the validity and acceptability of the results to HCOs
before final submission for ranking
Access of the HCOs to survey report after Apart from confidential aspects, availability of the reports for HCOs after
evaluation evaluation might show how they can attend to and improve the details of
their operations
Report turnaround time Time between the onsite visit and delivery of final survey report and
recommendations to the hospitals (e.g. it was claimed by the professionals
that the shorter this time the sooner the hospitals could identify and make
an effort to rectify the problems)
Consultatively driven standard A significant input from all stakeholders (e.g. providers of care, consumers
development process and purchasers, government, insurers and healthcare administrators)
specifically into accreditation programs’ standard development process
Different patterns of evaluation or standards Identical or different types of standards are applied for evaluating
for/in accordance with various hospitals different hospitals. Given the different mission of these hospitals, similar
standards might not generate a fair evaluation of their all activities
Feasibility of standards Whether HCOs are able to fulfill the accreditation standards in practice
Clarity of standards The intention, meaning and interpretation of the standards are
understandable for all participating groups (i.e. HCOs, surveyors)
Communication of accreditation standards to HCOs have access to the standards against which their performance is to
HCOs by accreditation programs be assessed
Consideration of documenting requirements The programs insist on the documentation of the services (i.e.
in accreditation standards encouraging evidence-based assessment)
The scope of the standards The coverage of all type of activities and services of HCOs by
accreditation standards, including hotel-type services and administrative
and financial activities
Inclusion of ‘outcome-related’ metrics in Given the argument that assuming a linear relationship between processes
accreditation standards and outcomes in healthcare is thought to be challenging, attention to
outcome-related indicators seems necessary, in addition to processes and
structures
Consideration of structure and process Unlike developed countries with well-organized structures and processes,
standards by accreditation programs in developing countries should still focus more on their structures and
developing countries processes, along with outcome indicators
Inclusion of ‘core clinical activities’ of HCOs The majority and core of the services rendered in HCOs
in accreditation standards are clinical, which are argued to be more influential in care delivery
processes
Regular review and update of accreditation † A regular review and update system set up specifically for the
standards standards
† The frequency of reviewing and updating process in a specific
period
(continued )

650
 Evaluation of accreditation † Accreditation

Table 2 Continued

Measure Explanation
.............................................................................................................................................................................

Participation (attraction) of HCOs’ staff
(especially clinical people) in accreditation
processes
A sound and reliable scoring system
The use of a self-evaluation system by
accreditation programs to ensure their
continued relevance to current practice of
HCOs
† This could increase the credibility of the accreditation programs’
requirements and facilitate their operationalization in HCOs
† This might be undertaken in the self-evaluation stage of HCOs (i.e.
preparation for the accreditation)
An evidence-based rather than judgemental system for allocation of the
scores to the related activities (more reliance on evidence for scoring)
Accreditation of HCOs based on newly emerged methods and
development of standards for new services afoot in HCOs

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Table 3 Organizational (micro) impact of accreditation programs

Measure Explanation
.............................................................................................................................................................................

Outputs of accreditation Increased compliance with accreditation standards: the number of HCOs met the
programs (mandatory) accreditation standards vis-à-vis previous accreditation
periods-measured based on a HCOs’ accreditation rank
Immediate tangible actions taken by HCOs before and after an accreditation
program to meet its requirements (e.g. holding meetings, setting up purpose-built
internal committees): This might refer to the degree of importance given to
accreditation programs by HCOs and could be measured through identifying those
efforts of the HCOs which are directed toward these requirements (e.g. during the
preparation phase)
Recommendations offered to HCOs by accreditation programs for improvement:
The percentage of initially failed HCOs which are subsequently successful as a
result of the guidance of (mandatory) accreditation programs
Outcomes of accreditation The substantive outcomes of accreditation programs for HCOs over time
programs (pre/post-accreditation) or in terms of accredited/non-accredited HCOs:
(1) Improved patients’ care
(2) Standardization of care processes in HCOs
(3) Enhanced patient and staff satisfaction
(4) Greater safety for patients and staff
(5) Improved financial performance of HCOs
(6) Improved inter-/intra-HCOs’ communication and information flows
(7) Professional development (learning outcomes of the accreditation programs
for the hospitals’ staff)
(8) Coherent organizational culture (encouraging same norms and language of
communication and shared knowledge in HCOs)
Minimal unintended and HCOs undergo a low rate of adverse effects from/through the process of
dysfunctional effects accreditation (e.g. tunnel vision, stress and tension)
HCOs are not driven towards dysfunctions (e.g. gaming) because of accreditation
programs
Indirect benefits of Financial benefits for HCOs (increased tariffs for services)
accreditation programs for Legitimacy for the HCOs, granted by accreditation programs in the form of
HCOs ranking, which might be construed in two ways (for a HCO):
† As a permission to continue its activity in its current state;
† As an element of reputation
Encouragement of HCOs to imitate their higher ranked similar organizations

651
Jaafaripooyan et al.
Hence, these measures might be considered either as a weak-
ness or strength for these programs. Nevertheless, most of
the measures are stated positively in that their exact opposite
could be also assumed as relevant in investigating the dys-
functional effects of an accreditation program. The following
section will briefly provide a discussion of the main points
presented in the tables.
Societal impact of accreditation programs
Table 1 demonstrates the measures which reflect the impact
of accreditation programs at a macro and societal level.
Accreditation has undeniably been an influential mechanism
for protecting society in the sense of safeguarding pubic
access to quality and safe healthcare [2]. The accreditation
programs play a key role in monitoring the reflection of
healthcare values (i.e. quality and excellence) by HCOs. Such
tasks are argued to be undertaken by ‘societal steering mech-
anisms’ from a macro perspective [61, p. 13]. Based on this
reasoning, accreditation could be conceived as a steering
mechanism in healthcare with its respective impact at the
societal level. The measures presented in this table are
expected to reflect societal aspects of the programs’ per-
formance. For instance, ‘society’s demand for a voluntary
accreditation program’ could be a sign of performance excel-
lence and success for these programs. As such, the ‘retention
rate of HCOs by a voluntary program’ accentuates the ben-
eficial, or otherwise, consequences of accreditation programs
when compared with other quality assessment and improve-
ment systems in a society. Efforts to operationalize public
involvement in the governance of these systems provided
greater objectivity and credibility to the accreditation process
[62]. Moreover, it has been argued that the provision of
information to the public about HCOs’ performance, given
the current ease of access to the information sources, has
become a key factor for successful accreditation programs
[63]. Regardless of the possible consequences such as the
misinterpretation of accreditation reports or overreaction to
negative data, the existing evidence backs the positive effects
of publicly releasing the accreditation results on HCOs’
evaluation results, besides enhancing public accountability
and quality of care [60]. The discernability of the accredita-
tion rating could be advantageous for the public to easily
identify the well-performed HCOs [64].
Different stakeholders may rely on accreditation results in
their decision-making. A growing number of state-run
accreditation programs could allude to the increased reliance
of governments on accreditation results to safeguard the
public access to quality healthcare [14]. Moreover, the intro-
duction of a ‘choose and book’ procedure by some advanced
health systems (e.g. NHS) warrants patients to think of
specific criteria against which they would select their desired
provider [65]. The information provided through accredita-
tion could serve as such criteria. By the same token, the
transparency of accreditation programs’ various stages for
accreditees and the responsiveness of the programs for
their decisions could turn them into an evidence-based
program [35].
652
Flexibility of an accreditation program to adapt to the
changes in its environment and accommodate the feedback
of different stakeholders could ensure its sustainability and
relevance. This openness to changes could transfer the pro-
grams into a learning organization which always incorporates
feedback in its development process and stays up-to-date.
Methodology of accreditation programs
Table 2 provides related ‘performance measures’ for judging
the functionality of accreditation. Surveyors and standards
are two main elements of any accreditation scheme [66].
Surveyors are envisioned as the ‘eyes, ears and hands’ of any
accrediting organization, without which the accreditation
process is argued to be unsustainable [67, p. 1]. Therefore, as
such, a detailed training program for new surveyors along
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with setting surveyor selection criteria are claimed to enhance
the reliability of accreditation [68]. As Pickering [69] indi-
cates, the training is essential in guiding the surveyors to
detect the gaming in the hospitals.
Standards are similarly a key element for accreditation,
against which HCOs’ performance is assessed. The choice of
standards, their focus and the level at which they are set are
crucial in determining the tone, acceptability and nature of the
accreditation programs [49]. Therefore, it is important that the
standards are concomitantly reviewed and kept aligned with
advances in healthcare and relevant to the services or organiz-
ations under their evaluation. There are various dimensions
that should also be taken into consideration while evaluating
accreditation standards. For instance, ‘the rate of clarity and
feasibility of standards for HCOs’ implies that standards
should be ‘understandable’ at first sight by those who perform
accreditation (i.e. surveyors) and are accredited (i.e. HCOs).
The Accreditation Canada institution believes in optimal, but
achievable (within the current state of the art) and surveyable
standards within the confines of resource constraints [66].
Application of a ‘consensual process’ for developing the
accreditation standards was also recommended by the experts.
Incorporation of ‘stakeholders’ voice’ in different stages of
accreditation is highly stressed [63] and is receiving growing
attention among accreditation agencies [62].
‘Outcomes performance measures’ are increasingly impor-
tant in healthcare. Lack of evidence supporting the assump-
tion that appropriately organized inputs could certainly lead
to desired outcomes in healthcare has accelerated the move-
ment towards using outcome indicators in evaluating hospi-
tals [38, 70]. de Walcque et al. [5] refer to ‘outcome
measures’ as the determinant of the ultimate impact of an
accreditation program. However, given the intangible nature
of these indicators, process and structure measures might be
preferred [70]. Despite the importance of outcomes, achiev-
ing quality outcomes through poor structures and processes
might also appear unlikely, as could be the case in developing
countries [14].
‘Inclusion of clinical indicators’ in the accreditation stan-
dards could increase the clinician’s involvement, which is
vital for successful introduction and implementation of
accreditation programs [71], in different stages of the

accreditation process [41]. This is noticed and operationalized
by various programs. For instance, in the USA, since 1997,
JCAHO has linked clinical outcomes indicators to accredita-
tion process through ORYX-initiative integrating outcomes
and other performance measurement data into the accredita-
tion process [72]. ACHS has developed the performance and
outcome service to increase the clinical components and
indicators in its new accreditation program [73, 74].
The existence of a regular review and update system for
the entire accreditation process, specifically the standards,
was widely reflected by the respondents. In JCAHO, stan-
dards are reviewed every year for hospitals and every 2 years
for other HCOs, and Accreditation Canada reviews its stan-
dards every 2 years. The self-evaluation system for accredita-
tion programs ensures the relevance of their standards to the
newly emerging activities of HCOs. It further helps assimilate
the advancements in the structure and development of
accreditation programs.
Emphasis on ‘documenting’ by HCOs in accreditation
standards could be a key pointer to ‘evidence-based’ evalu-
ation of HCOs. ‘Documentation requirements’ for HCOs by
these programs are a key element indicative of ‘reliability’ of
accreditation processes [68, p. 112].
Organizational impact of accreditation programs
The impact of accreditation programs on HCOs at the micro
level is explained in Table 3. It comprises all forms of
immediate (outputs), long-lasting (outcomes), indirect and
dysfunctional effects of the programs on HCOs. Enhanced
compliance of HCOs with the requirements of accreditation
programs is the most tangible sign of their effectiveness [30].
Comparing this reaction (with the exclusion of symbolic
compliance) over a specific period or different hospitals
might signify that the HCOs have improved their ability to
meet the standards of the programs (i.e. the boosted capabili-
ties of HCOs for achieving accreditation standards). This
might be referred to as the ‘capacity development’ role of
accreditation programs.
Tangible actions and efforts of HCOs (e.g. holding meet-
ings and setting up a specific internal committees) to meet
the programs’ requirements could signal the importance
given by HCOs to satisfying the requirements of accredita-
tion programs. These actions de facto orchestrate the circum-
stances for further and prolonged improvements in the
HCOs. Recommendations offered by accrediting groups for
boosting quality in HCOs serve to fulfill ‘improvement and
change’ intentions of these systems in organizations under
evaluation [75, p. 161].
Despite these initial effects, real impact of accreditation
should be seen through its capacity to lead to sustainable
improvements in patient care quality and safety [24, 76],
from two perspectives; within HCOs through pre- and post-
accreditation stages and between accredited and non-
accredited HCOs.
There have always been concerns over how to enhance the
effectiveness and efficiency of evaluation and control mech-
anisms while maximizing their intended consequences on
Evaluation of accreditation † Accreditation
organizations. Policymakers are increasingly becoming
worried about dysfunctional and unintended consequences
of quality improvement initiatives [77]. Therefore, the merits
of accreditation programs’ could be also scrutinized for their
unintended and dysfunctional effects on HCOs (e.g. the pro-
grams may cause physicians to focus mostly on measured
care at the expense of unmeasured care).
Accreditation could be seen as a source of economic gain
and legitimacy for HCOs. These organizations are permitted
to work in some communities on the condition that they
receive an accreditation award (i.e. legitimacy). Alternatively,
they might be allowed to charge higher tariffs or have service
contracts with third-party organizations based on the level of
their ranking. In addition, these programs provide a chance
for HCOs to identify and emulate those organizations which
have received the highest ranking in accreditation.
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Final considerations
With the paucity of research investigating performance evalu-
ation of accreditation programs, this study brings together a
number of generic, yet workable, measures which could be
utilized for assessing the value and merits of an accreditation
scheme in healthcare [cf. 78, 79]. The measures are some-
what in the form of general pathways laying the groundwork
for further examination of the programs’ performance and
effectiveness, which could be considered as a departure point
for future research on accreditation.
This study can be conceived as unique and novel for its
direct approach to identifying and suggesting performance
measures for evaluating accreditation programs in healthcare.
Some measures could be utilized as a decision support by
authorities and policymakers to appraise their programs over
a specific period. Alternatively, some might be also used to
guide the initiation of a new program in a country. Data
from both academic and professional contexts were included,
in order to yield more comprehensive and plausible results
and reflect diverse and complementary perspectives and
experiences on accreditation. In terms of the application of
the measures developed, the features of given accreditation
program and the context in which the program operates
should be considered. First step/steps in the assessment of
an accreditation program, for example, could be identifying
relevant measures suiting that specific program and context.
Along with the modest effort of this study to contribute to
the scant knowledge of performance measurement and
improvement of accreditation in healthcare, the following
limitations should be also recognized for this research. First,
although we conducted a rather comprehensive search for
experts, it is always possible for some to be missed, particu-
larly with our snowball sampling. Second, the measures are
the result of a qualitative and perceptual process and, there-
fore, they are on the verge of being judgmental and not gener-
alizable in quantitative sense. Third, selecting the group of
professionals from only one country is a limiting factor in
comparison with other two extended groups. Such a selection
was due, on one hand, to the intention of the study to form a
653
Jaafaripooyan et al.
diverse participant group and, on the other hand, to the data
access restraints, as explained earlier. Fourth, despite the fact
that a generic form of the accreditation was conceptualized
for the respondents, an intrinsic weakness in seeking opinions
from three sources, which may have very different orientations
and experience of accreditation, remains. Since the data from
the various groups were not intended to be compared, but
combined, the effect of contextual differences could be argu-
ably alleviated. Finally, the study is not claimed to be
all-encompassing in its coverage of measures related to the
performance of accreditation programs and other indicators
might be explored. Accordingly, it is essential that further and
persistent empirical research is performed in an attempt to
seek confirmatory signs and build additional understanding of
these performance measures.
Acknowledgments
The authors would like to acknowledge the Iranian Ministry
of Health and Medical Education and Tehran University of
Medical Sciences by which this study was supported. Special
thanks should also go to two anonymous reviewers who pro-
vided valuable comments on this paper.
Funding
This study has been financially supported by the Iranian
Ministry of Health and Medical Education (MOHME).
Appendix
654
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