Claudia A. S. Araujo (Corresponding Author)

A SYSTEMATIC REVIEW OF HOSPITAL ACCREDITATION IMPACT ON
HEALTHCARE QUALITY DIMENSIONS
Downloaded from https://academic.oup.com/intqhc/advance-article/doi/10.1093/intqhc/mzaa090/5890368 by Cornell University Library user on 17 August 2020

Claudia A. S. Araujo (corresponding author)
- Coppead Graduate School of Business, Federal University of Rio de Janeiro-RJ, Brazil.
- Fundação Getulio Vargas’s Sao Paulo School of Business Administration -FGV/EAESP, São Paulo-SP,
Brazil.
E-mail: claraujo@coppead.ufrj.br
Phone number: 55-21-99363-3966
Marina Martins Siqueira

- Coppead Graduate School of Business, Federal University of Rio de Janeiro-RJ, Brazil.
Ana Maria Malik

- Fundação Getulio Vargas’s Sao Paulo School of Business Administration -FGV/EAESP, São Paulo-SP,
Brazil.
Running Title: Hospital Accreditation Impact.
Word count for the abstract: 249 words.
Word count for the text of the manuscript: 2,933
© The Author(s) 2020. Published by Oxford University Press in association with the International Society for Quality in Health
Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
HOSPITAL ACCREDITATION IMPACT ON HEALTHCARE QUALITY
DIMENSIONS: A SYSTEMATIC REVIEW

Purpose. To systematically review the impact of hospital accreditation on healthcare quality
indicators, as classified into seven healthcare quality dimensions.
Data source. We searched eight databases in June 2020: EBSCO, PubMed, Web of Science,
Emerald, Proquest, Science Direct, Scopus, and Virtual Health Library. Search terms were
conceptualized into three groups: hospitals, accreditation, and terms relating to healthcare
quality. The eligibility criteria included academic articles that applied quantitative methods to
examine the impact of hospital accreditation on healthcare quality indicators.
Data extraction. We applied the PICO framework to select the articles according to the
following criteria: Population - all types of hospitals; Intervention - hospital
accreditation; Comparison – quantitative method applied to compare accredited vs. non-
accredited hospitals, or hospitals before vs. after accreditation; Outcomes - regarding the seven
healthcare quality dimensions. After a critical appraisal of the 943 citations initially retrieved, 36
studies were included in this review.
Results of data synthesis. Overall results suggest that accreditation may have a positive impact
on efficiency, safety, effectiveness, timeliness, and patient-centeredness. In turn, only one study
analyzes the impact on access, and no study has investigated the impact on equity dimension yet.
Conclusion. Mainly due to the methodological shortcomings, the positive impact of
accreditation on healthcare dimensions should be interpreted with caution. This study provides
an up-to-date overview of the main themes examined in the literature, highlighting critical
knowledge-gaps and methodological flaws. The findings may provide value to healthcare
stakeholders in terms of improving their ability to assess the relevance of accreditation processes.

Keywords. Healthcare quality, Hospital accreditation, Quality assessment, Healthcare quality
dimensions, Healthcare quality indicators.
1. Introduction
Healthcare quality (HQ) is a broad concept that can be defined as “the degree to which health
services for individuals and populations increase the likelihood of desired health outcomes and
are consistent with current professional knowledge” [1:3] and comprises multiple dimensions,
including: safety, patient-centeredness, timeliness, equity, access, efficiency and effectiveness
[2,3]. However, accurately assessing HQ is difficult, as there is a lack of formal systems to
monitor and ensure consistency in healthcare delivery [4, 5]. Therefore, hospital accreditation
has been frequently adopted worldwide to assess and improve healthcare service quality [6, 7].
Hospital accreditation programs, defined as the “systematic assessment of hospitals against
accepted standards” [8:156], are conducted by independent bodies, external to the hospital
structure, usually comprising non-governmental and non-profit organizations. The process
includes staff training, the establishment of a team project, selection of standards to be followed,
and implementation of specified requirements. It also comprises survey visits by a
multidisciplinary healthcare team, leading to a detailed report of identified areas of improvement
and the next cycle of follow-up visits [8, 9].
Two important benefits of the accreditation process are the standardization of procedures and
internal policies and the establishment of management systems [8, 10]. In addition, the adoption
of pre-established and explicit standards to guide processes of care may also contribute to patient
safety, especially when factoring in well-established metrics such as medication errors [11].
However, both systematic and non-systematic literature reviews conducted previously indicate

that there is no consensus regarding the impact of accreditation on hospital outcomes [12 – 18].
Alkhenizan and Shawn [17] presented several studies showing that accreditation programs
improved clinical outcomes, while Brubakk et al.’s [12] systematic review did not find evidence
to support a link between hospital accreditation and measurable changes in healthcare quality
indicators (HQI). These controversial results can be explained in part by the difficulty in
comparing complex and heterogeneous interventions like accreditation programs [12, 14, 15,
19]. Also, some previous systematic reviews do not specify the methodological design of
selected studies and the accreditation types, stages, or outcomes [16 – 18].
While acknowledging previous studies, these ambiguous results highlight the importance of
employing a more systematic approach to review the literature and complement such efforts [7].
Therefore, this study attempts to systematically review and synthesize pieces of evidence from
studies that quantitatively examined differences in HQI before vs. after hospital accreditation
(pre-post-A) or among accredited vs. non-accredited (AxNA) hospitals. Furthermore, this review
analyzes the impact of hospital accreditation in seven healthcare quality dimensions (HQD),
which has already been widely addressed in the healthcare literature (Table 1).
--------------------------- TABLE 1 ---------------------------
2. Method
This study followed the PRISMA protocol [21] to identify, assess, and select existing articles
(Figure 1). The search was performed in June 2020, including articles published up to that date,
across eight databases that cover international content in the fields of management and
healthcare: EBSCO, PubMed, Web of Science, Emerald, Proquest, Science Direct, Scopus, and

Virtual Health Library (BVS). The search strategy included combined terms using the Boolean
operators ‘AND’ and “OR” (Table 2). As some HQI, like the length of stay (LOS), can affect
“operational” and “financial” indicators, the researchers decided to include these terms in the
search to better capture the accreditation impact on hospitals.
--------------------------- TABLE 2 ---------------------------
The eligibility criteria for our study limited the nature of texts to academic articles, with
full online texts available, written in either English or Portuguese. Selected articles empirically
assess the impact of hospital accreditation on HQI, through quantitative methods. The inclusion
criteria are based on the PICO framework [22]: Population – all types of
hospitals; Intervention – hospital accreditation; Comparison – pre-post-A or AxNA
hospitals; Outcomes – regarding the seven HQD (Table 1). We excluded review papers, articles
analyzing perceptions about the accreditation impact, and articles dealing with accreditation for
specific services, like bariatric surgery, or cardiac treatments. Aiming at a broad chronological
examination of the topic, no filters were applied regarding the year of publication and the
journals impact factor.
Search results were imported into EndNote, and duplicates were removed. Basic
information from the remaining articles was exported to a Microsoft Excel sheet, and two of the
authors of this study independently analyzed titles and abstracts. In the next stage, the three
authors independently conducted a full article assessment, following the pre-specified inclusion
criteria. In order to increase the reliability of the process selection [23], the remaining
disagreements among the three authors were resolved in order to reach 100% agreement. Next,

the authors applied the snowball strategy to screen reference lists of selected studies, looking for
potentially relevant studies. Data extraction was performed by one author and revised by a
second, using a standardized Excel spreadsheet, in which columns represent the categories of
analysis. The included studies were classified according to several descriptive and analytical
aspects, including authors; year and journal of publication; country; research method; accrediting
institution; type of care - e.g. preventive, acute or chronic [5]; impact of accreditation – null
(differences without statistical significance), positive, or negative (differences with statistical
significance) [16]; study method and data collection procedure [16]; and HQD assessed.
3. Results
The initial search retrieved 943 articles, with 198 duplicated. The title and abstract
analysis resulted in the exclusion of 605 articles. In the full assessment of the 140 articles, 109
articles were excluded for falling outside the scope of this review, resulting in a final list of 31
articles. The full article assessment was conducted independently by two authors, whereby
studies were classified as ‘within the scope’, ‘outside the scope’ or ‘in doubt’. The authors
reached a 92% consensus in the classification (i.e. attributing similar classifications in 129/140
studies). For the 11 studies where at least one author classified as ‘in doubt’, or, authors gave
distinct classifications, the decision was discussed by all authors, resulting in the exclusion of all
non-consensual cases. Finally, the snowballing of the reference list of selected studies generated
five additional papers, yielding 36 empirical studies analyzed in this review (Figure 1).
--------------------------- FIGURE 1 ---------------------------

3.1 Characteristics of Studies
The 36 selected studies were published between 1988 and 2019 (see Table 3). Regarding
the research country, the most frequent are the United States (8/36;22%) and Saudi Arabia
(6/36;17%). Regarding continent, 48% of the articles (17/36) were conducted in Asia, 22%
(8/36) in Europe, 22% in North America (8/36), and 8% in Latin America (3/36).
The studies were published in 24 different scholarly journals, with a mean Impact Factor
of 2.226. The International Journal for Quality in Health Care is the most frequently
encountered, journal, having published seven of the studies in the sample (7/36;19%), followed
by BMC Health Services Research, with four studies (4/36;11%).
Twenty articles (20/36;56%) compare AxNA hospitals, and 16 (16/36;44%) compare a
same hospital pre-post-A. The most common accrediting institution is the Joint Commission - JC
(17/36;47%), followed by Accreditation Canada International – ACI (4/36;11%). Five studies
(14%) do not specify the institution, and the remaining studies (10/36;28%) analyze different
international accreditations. There are studies conducted in public (11/36;30%), private
(4/36;11%), and teaching (8/36;22%) hospitals and the number of hospitals analyzed in each
study varies from 1 to 5,070.
Regarding the methodology, most articles (33/36;92%) adopt a purely quantitative
approach, while 8% (3/36) are quali-quantitative. Among the most applied statistical tests are the
regression models (15/36;42%), followed by Chi-square (11/36;30%), ANOVA (9/36;25%),
Mann–Whitney (9/36;25%), and Students’ t-test (8/36;22%). Thirty-four articles (34/36;94%)
adopted a 0.05 significance threshold.

Most studies (23/36;64%) have an observational design, followed by quasi-experimental
studies (12/36;33%). Only one study (1/36;3%) presents an experimental design, with a

Randomized Controlled Trial (RCT). RCTs are acknowledged as a gold standard in clinical
evidence [24], while mixed-methods allow to produce more robust and compelling results when
approaching complex and multifarious phenomenon such as hospital accreditation [25]. As
presented in supplementary material, most studies (26/36;72%) were attributed a low level of
evidence due to a observational or descriptive study design. Nearly half the studies (16/36;44%)
were attributed a high risk of performance bias because accreditation effects were not controlled
for confounding variables. In turn, most studies (30/36;83%) present a low or medium risk of
detection bias, given that they employ mostly well-known, valid, and justifiable quality
indicators to measure the accreditation impact. In general, the studies present a medium overall
quality assessment (22/36;61%), suggesting room for content and methodological improvements.
--------------------------- TABLE 3 ---------------------------
3.2 Accreditation Impact
The effects of hospital accreditation on HQI are mostly positive. Seventeen articles
(17/36;47%) report positive impact for all the indicators analyzed, 14 (14/36;39%) present mixed
results, five (5/36;14%) indicate null effect of accreditation, and zero (0/36;0%) present a solely
negative impact (see Table 4).
Concerning the accreditation institution, the four studies that analyze the ACI apply the
pre-post-A approach and report a positive impact on effectiveness, efficiency, and safety.
Regarding the 17 studies that analyze hospitals accredited by the JC, eight (8/17;47%) report a
positive impact on effectiveness, safety, patient-centeredness and/or efficiency [27, 29, 30, 35,
41, 43, 51, 60], five (5/17;29%) indicate a null impact on patient-centeredness, safety, efficiency
and/or effectiveness [6, 31, 44, 51 , 59], and six (6/17;35%) present a mixed impact of

accreditation on some HQI [36, 38, 42, 56, 57, 60]. The remaining articles (15/36;42%) analyze
different accreditations or did not specify the institution.
--------------------------- TABLE 4 ---------------------------
Concerning the HQD, the articles focus mainly on safety (18/36;50%), efficiency
(6/36;44%), and effectiveness (15/36;42%). Few studies investigate the impact on patient-
centeredness (7/36;19%), timeliness (2/36;5%), or access (1/36;3%). Zero studies analyze the
accreditation impact on equity. (Table 5).
--------------------------- TABLE 5 ---------------------------
Most articles (12/18;67%) indicate a positive impact of accreditation on safety indicators
(evidence-based care, lower infection rates, adverse events, ulcer incident), while three articles
(3/18;17%) indicate a mixed impact for acute care [38, 41,50], and three (3/18;17%) report a null
impact on this dimension [39, 44, 60].
Sixteen articles analyze the impact of accreditation on efficiency. Thirteen studies
(13/16;81%) report a positive impact of accreditation on efficiency (staff turnover, job rotation,
medical records, nursing documentation, leadership, facilities and human resources, professional
satisfaction, physical infrastructure, and waste management). One study (1/16;6%) observes
positive and null impact of JC accreditation on efficiency [41] and two articles (2/16;13%) reveal
a null impact on turnover [59] and on costs per patients, resource utilization, and human
resources [26].

Eight out of 15 articles (8/15;53%) that assessed indicators related to
the effectiveness report a positive impact of accreditation (LOS, mortality and readmission rates).
Four (4/15;27%) report a null effect [53, 6, 57, 59], two articles (2/15;13%) report both positive
and null effect on the indicators analyzed [36, 55], and Bogh et al. [54] find both positive and
negative impact of accreditation on non-psychiatric hospitals in Denmark. The effectiveness
improved for diabetes, but processes related to heart failure, breast cancer and diagnostics are
shown to be negatively affected by accreditation.
Seven articles analyze the impact of accreditation on patient-centeredness, and in four of
them (4/7;57%) the impact is null. The remaining three studies (3/7;43%) report a positive
impact of accreditation: two related to patient experience [57, 60], and one regarding patient
rights and privacy [32]. Regarding timeliness, Markovic-Petrovic et al. [55] report a reduction in
waiting time for a health or surgical check, pre-post-A in two tertiary hospitals in Serbia.
Furthermore, a Japanese study in a private teaching hospital (Inomata et al. [56]) identifies a
higher pre-anesthesia time and a lower anesthesia induction time post-accreditation, but a null
effect on total procedure/surgery time.
Finally, the only study investigating access, conducted in public tertiary hospitals in
Saudi Arabia [45], finds a null effect of accreditation. The authors used five items to describe
ease in accessing healthcare services: hospital bed availability, absence of difficulties in patient
admission, ease in obtaining an appointment, referral forms to specialized clinics, and follow-up
care. Regarding equity, no study approached the impact of hospital accreditation on this
dimension. It is worth noting that even though access and equity measures are multifactorial
construct and complex to measure, they are important determinants of healthcare quality [2] and
should ideally be pursued by hospital accreditation interventions.

4. Discussion
Although the general results indicate a positive impact of hospital accreditation on HQD,
some aspects should be considered. The high number of accrediting institutions within the
sample draws attention to the great differences in the methodological setup of the hospital
accreditation programs examined.
Also, the studies examined substantially different hospitals, in terms of bed sizes, geographic
regions, teaching status, patients’ case-mix, ownership, disease areas and service type.
Additionally, aspects such as staff changes, and other organizational adjustments may affect the
association between accreditation and the measured HQI [6, 40, 58]. Therefore, isolating the
“accreditation factor” for its impact on quality measures is a challenge and those studies cannot
exclude the possibility that uncontrolled factors or other institutional characteristics might
confound the results [30, 55].
A further complication is that it is not clear if the improvements observed in accredited
hospitals are related to the accreditation itself or if accreditation merely reveals hospitals that are
more motivated to comply with healthcare guidelines and to implement quality improvements. In
scenarios where accreditation is a choice, there is a possibility that hospitals with better and more
resources be more prompt to undergo this process to confirm their excellence, potentially biasing
the studies toward finding a benefit of accreditation [6, 61].
Regarding the comparison between AxNA hospitals, although the results in general indicate
better results for those that are accredited, it does not ensure the positive impact of accreditation
on HQI. One concern is that the studies may be comparing AxNA hospitals that are in different
stages of the accreditation process. Also, cross-sectional studies need to account for pre-existing
differences between AxNA hospitals.

Similarly, comparing pre-post-A periods entails some limitations, and it is not possible to
attribute improvements or worsening in the indicators to the accreditation process. In
longitudinal studies, exogenous variables can affect the indicators being analyzed: the longer the
study, the greater the chance that non-anticipated elements interfere with the results [40].
Additionally, given that accreditation often aims at a continuous improvement process, it is hard
to define the endpoint dividing the “before” and “after” periods. Even when authors isolate
organizational changes, if the study considers newly accredited hospitals, it is possible that the
full benefits of changes implemented during and because of the accreditation process may
emerge in a later point not covered in the study, as observed in Devkaran and O’Farrell’s [38,
42] results. Finally, imbalance in the evaluated time periods pre-post-A can also compromise the
results [33]. The negative results may also be attributed to a more accurate data-system and a
higher compliance in reporting incidents, as medication errors or hospital infection cases [38, 42,
50].
An additional methodological fragility is that many studies in this sample presented a size
difference of at least 50% between comparison groups, which can interfere with the robustness
of results [35, 43]. Likewise, many studies did not specify the resulting margin of error and
confidence level for the sample examined or did not detail critical information for assessing the
sample size adequacy. Small samples may hamper the generalization of findings to other settings
[32, 38, 40, 43, 52, 53, 55, 56, 58].
Furthermore, the impact assessment is restricted to the HQI measured, the specific hospital
departments and disease areas focused on the studies. Finally, the quantitative evidence should
ideally be complemented by qualitative data, helping to understand the determinants and
consequences of accreditation that are difficult to measure objectively. In this sense, mixed-

method studies can contribute to theoretical developments in this literature, uncovering factors
that drive or hamper HQ. As it stands currently, from the 36 selected studies, only three (8%)
adopted quali-quantitative approaches.
5. Conclusion
This study aimed to systematically review the impact of hospital accreditation on healthcare
quality indicators, as classified into seven healthcare quality dimensions. Our results indicate that
accreditation may have a positive impact on efficiency, safety, effectiveness, patient-
centeredness, and timeliness dimensions. Also, it seems that accreditation has no impact on
access indicators. However, these results should be analyzed carefully due to the methodological
pitfalls pointed out previously.
This study’s limitations include the risk of overlooking some key literature [18], given the
fact that studies not published in peer-reviewed journals or indexed in electronic databased were
excluded; this also includes potentially important literature that may have been undiscovered due
to the use of different keywords. In addition, this systematic review focused on studies
empirically and quantitatively examining the impact of accreditation on quality dimensions,
comparing accredited vs. non-accredited hospitals or hospitals before vs. after accreditation.
Thus, any relevant study outside these limits were not considered eligible. Secondly, the selected
studies comprised distinct research contexts and methods, thus hindering a statistical meta-
analysis [16]. Thirdly, the heterogeneity and methodological shortcomings of studies constrain
the generalizability of this review findings. Despite these limitations, our study provides an up-
to-date overview of the main themes and subthemes examined in the literature, highlighting
critical knowledge-gaps and methodological flaws. These findings also benefit healthcare

stakeholders by improving their capability to assess the relevance of the accreditation processes.
Also, the use of a more detailed synthesis and new categories of analysis helped to extend the
findings of previous reviews.
Future investigations may benefit from expert panels to assess the quality of studies, thereby
gathering different viewpoints [15]. Also, considering the time, effort, and resources needed for
accreditation programs, future studies can estimate the costs involved and the financial benefits
associated with or resulting from hospital accreditation. Finally, given that the equity dimension
was not analyzed, and that few studies have assessed access, timeliness and patient-centeredness,
future research could investigate the impact of accreditation on these dimensions.
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Table 1. Healthcare Quality Dimensions
Quality Description
dimension
Effectiveness The healthcare service is delivered based on scientific knowledge and results in improved health outcomes.
Health services are provided to all who could benefit, refraining from providing services to those not likely to
benefit.
Efficiency The healthcare service is delivered in a manner which maximizes resource use and avoids waste, including waste
of equipment, supplies, ideas, and energy. It aims the greatest health improvement at the lowest cost, with the
most advantageous cost-benefit.
Access The healthcare is timely, geographically reasonable, and provided in a setting where skills and resources are
appropriate to medical need.
Patient- The healthcare is respectful of and responsive to individual patient preferences, needs, culture and values. There
centeredness is a conformity to patient preferences regarding patient-practitioner relation, the service accessibility and
amenities, the effects, and costs of care.
Equity The healthcare does not vary in quality because of personal characteristics such as gender, ethnicity, geographic
location, and socioeconomic status. It accounts for fairness in the distribution of care and its effects on health,
Timeliness The healthcare is delivered in a timely manner, reducing waiting times and harmful delays for both those who
receive and those who give care.

Safety The healthcare is delivered in a manner which minimizes risks and harm to service users, avoiding injuries to
patients from the care that is intended to help them.
Source: Adapted from Donabedian [2]; Institute of Medicine [3]; World Health Organization, [20].
Table 2. Search strategy

Strategy Terms
#1 “hospital” OR “hospitals” (in the abstract, title and/or subject of the publication)
#2 “accreditation” (in the title)
#3 “quality of care” OR “patient outcomes” OR “patient safety” OR “operational” OR “financial”
(in the abstract, title and/or subject of the publication)
#4 #1 AND #2 AND #3
Source: Developed by the authors.

Figure 1. Diagram of selection and evaluation
Identification Systematic search in

databases (n = 943)
Duplicates
(n = 198)
Screening Abstract assessment

(n = 745) Inadequate scope of
analysis (n = 605)
[Qualitative; Non-empirical;
Non-academic; Based on
perceptions about the impact]
Eligibility Full article assessment
(n = 140)
Inadequate scope of
analysis (n = 109)
[Non-empirical; Not
Selected studies comparing pre-post-A or AxNA
Selection
(n = 31)
Snowballing (n = 5)
[Snowballing the reference list
of selected studies and previous
Final sample analysis SRs on related topics]
(n = 36)
Source: Based on PRISMA flow diagram [21]

Table 3. Studies characteristics
Author, year [ref] Journal (Impact Research objective Study type (evidence level)
(country) Factor) Data collection
Hadley and Hospital and To determine whether accreditation by JC or certification
McGurrin, 1988 Community by the HCFA are related to indicators of quality of care. Observational - cross-sectional study (4b)
[26] Psychiatry (NA) Secondary: IMHO-84 survey.
(United States)
Chen et al., 2003 Health Affairs To examine the association between JC accreditation of
[27] (4.381) hospitals, those hospitals' quality of care, and survival Observational - cross-sectional study (4b)
(United States) among Medicare patients hospitalized for acute Secondary: CCP database.
myocardial infarction.
Sekimoto et al., Am J Infect To measure the impact of hospital accreditation on
2008 [28] Control (1.971) infection control programs. Observational - descriptive study (4b)
(Japan) Primary: researchers` questionnaire.\
Lutfiyya et al., Int J Qual Health To determine whether quality measures used in the US Observational - cross-sectional study (4b)
2009 [29] Care (1.340) Centers for Medicare and Medicaid Services Hospital Secondary: Hospital Compare.
(United States) Compare database differed for critical access hospitals
based on JC accreditation status.
Lichtman et al., Stroke (6.058) To determine whether hospitals certified within the first
Observational - cross-sectional study (4b)
2009 [30] years of the JC program had better outcomes than
Secondary: AHA, MEDPAR and
(United States) noncertified hospitals before the start of the certification
Medicare Enrollment Database.
program.
Sack et al., 2010 BMC Health To assess the relationship between patient satisfaction (as
Observational - descriptive study (4b)
[31] Serv Res (1.932) measured by the recommendation rate) and accreditation
Primary: Picker Patient Experience
(United States) status.
Questionnaire.
Shaw et al., 2010 Int J Qual Health To identify systematic differences in quality management
[32] Care (1.340) between hospitals that were accredited, or certificated, or
Primary: MARQuIS questionnaire.
(Europe) neither.
Kim et al., 2010 Korean J Radiol The purpose of this study was to evaluate any Quasi-experimental - before-and-after
[33] (3.730) improvement in the quality of abdominal computed study (2d)
(Korea) tomography (CT) after the utilization of the nationally Secondary: medical records. Primary:
based accreditation program. experts` assessment.

Sack et al., 2011 Int J Qual Health To assess the relationship between patient satisfaction and
[34] Care (1.340) accreditation status.
Primary: Picker patient experience
(Germany)
questionnaire.
Schmaltz et al., J Hosp Med To examine the association between JC accreditation

Observational - case-control study (3d)
2011 [35] (2.276) status and both absolute measures of, and trends in,
Secondary: Hospital Compare,
(United States) hospital performance on publicly reported quality
accrediting institution records.
measures for common diseases.
Lichtman et al., Neurology To measure outcomes after ischemic stroke for hospitals
2011 [36] (8.689) with and without JC
Secondary: Medicare Enrollment
(United States)
Database and medical records.
Al-Awa et al., Res J Med Sci To determine if the accreditation process has a positive
Quasi-experimental - before-and-after
2011 [37] (N/A) impact on patient safety and quality of care
study (2d)
(Saudi Arabia)
Secondary: medical records.
Devkaran and BMJ Open To evaluate whether accredited hospitals maintain quality
O’Farrell, 2014 (2.376) and patient safety standards over the accreditation cycle
[38] by testing a life cycle explanation of accreditation on
study (2d)
(United Arab quality measures.
Emirates)
Shaw et al., 2014 Int J Qual Health To investigate the relationship between ISO 9001
[39] (Europe - 7 Care (1.340) certification, healthcare accreditation and quality Observational - cross-sectional study (4b)
countries) management in European hospitals. Primary: on-site hospital audits.
Al-Sughayir, Saudi Medical To investigate whether the mental health accreditation

2014 [40] Journal (1.055) program drives improvements in the clinical practice of
study (2d)
(Saudi Arabia) giving PRN antipsychotic medications for psychiatric
inpatients.
Song, Li, and BMC Pharmacol To discuss the effectiveness of accreditation in the Quasi-experimental - before-and-after
Zhou, 2014 [41] Toxicol (2.103) outpatient settings, regarding to antibacterial overuse, study (2d)
(China) misuse and its related expenditure. Secondary: archives of the hospital Drug
& Therapeutics Committee.

Devkaran and BMC Health To examine the impact of hospital accreditation on quality
O’Farrell, 2015 Serv Res (1.932) measures.

Quasi-experimental - interrupted time
[42]
series (2d)
(United Arab
Emirates)
Halasa et al., East Mediterr To assess the economic impact of hospital accreditation
2015 [43] Health J (0.383) on 5 structural and outcome hospital performance Observational - case-control study (3d)
(Jordan) measures in Jordan. Secondary: medical records.
Bogh et al., 2015 Int J Qual Health To examine whether performance measures improve more
Observational - historical follow-up study
[44] Care (1.340) in accredited hospitals than in non-accredited hospital.
(3d)
(Denmark)
Secondary: national clinical registries.
Aboshaiqah, J Adv Nurs To compare patients’ assessment of quality of care
Alonazi and (2.376) provided by public tertiary hospitals grouped according to Observational - descriptive study (4b)
Patalagsa, 2016 accreditation status. Primary: questionnaire.
[45]
(Saudi Arabia)
Al-Sughayir, Int J Ment To investigate whether hospital accreditation drives

2016 [46] (Saudi Health Syst improvements for the LOS in psychiatric inpatients.
study (2d)
Arabia) (1.986)
Berssaneti et al., Rev Esc Enferm To evaluate whether accredited health organizations Observational - descriptive study (4b)
2016 [47] (Brazil) USP (0.945) perform better management practices than non-accredited Primary: self-evaluation questionnaire of
ones. the EFQM model.
Bogh et al., 2016 Int J Qual Health To assess changes over time in quality of hospital care in Experimental - Randomized Controlled
[48] (Denmark) Care (1.340) relation to the first accreditation cycle. Trial (1c)
Secondary: national clinical registries.
Habib et al., 2016 Int J Occup To assess the relationship between status of accreditation Observational - descriptive study (4b)
[49] (Lebanon) Environ Health among hospitals and compliance with Occupational health Primary: questionnaire and interview
(0.509) and safety (OHS) accreditation standards. data.
Janati et al., 2016 Bali Medical To analyze the effect of accreditation on three indicators Quasi-experimental - non-randomized
[50] Journal (N/A) related to patient safety and hospital care quality. trial (1d)
(Iran) Primary: on-site hospital evaluation.
Nomura, Silva Rev Lat Am To analyze the quality of nursing documentation by

and Almeida, Enfermagem comparing the periods before and after the preparation for
study (2d)
2016 [51] (0.979) the hospital accreditation.
(Brazil)
Al-Sughayir, Int J Ment To investigate whether hospital accreditation drives

2017 [52] (Saudi Health Syst improvements for administered pro re nata
study (2d)
Arabia) (1.986) benzodiazepines in psychiatric inpatients.
Almasabi and Int J Health To examine the impact of CBAHI on quality of care.
Thomas, 2017 Plann Manage Observational - descriptive study (4b)
[53] (1.450) Primary: Semi-structured interviews,
(Saudi Arabia) questionnaire.
Bogh et al., 2017 Int J Qual Health To identify predictors of the effectiveness of hospital Quasi-experimental - before-and-after
[54] Care (1.829) accreditation on process performance measures study (2d)
(Denmark) Secondary: hospital registries.

Markovic- Vojnosanitetski To investigate if the accreditation process has an effect on
Petrovic et al., Pregled (0.272) the difference in values of health care quality indicators.
study (2d)
2018 [55]
Secondary: annual hospital performance
(Serbia)
reports.
Lam et al., 2018 BMJ (2.881) To determine whether patients admitted to accredited
[6] hospitals have better outcomes than those admitted to non- Observational - case-control study (3d)
(United States) accredited hospitals reviewed through state surveys and Secondary: Medicare, Medicaid.
whether accreditation by the JC confers any additional Primary: HCAHPS questionnaire.
benefits.
Inomata et al., PLOS ONE To evaluate the impact of JCI requirements on time
Observational - case-control study (3d)
2018 [56] (Japan) (2.776) periods in the operating room.
Andres et al., BMC Health To evaluate the longitudinal impact of accreditation on

2019 [57] (Hong Serv Res (1.932) patient experience in a publicly funded university teaching
Primary: Picker Patient Experience
Kong) hospital.
Questionnaire.
Oliveira et al., Revista Latino- To analyze the influence of Accreditation on the
2019 [58] (Brazil) Americana De professional satisfaction of nursing workers. Observational - descriptive study (4b)
Enfermagem Primary: IWS questionnaire.
(0.979)
Wardhani et al., BMC health To explore the association of hospital characteristics and
2019 [59] services research market competition with hospital accreditation status and
Secondary: online national hospitals
(Indonesia) (1.932) to investigate whether accreditation status differentiate
database and hospital accreditation report.
hospital performance.
Yildiz et al., 2019 Int J Health Plann To verify the effects of certification and accreditation on
[60] Manage (1.450) hospital quality
Primary: QMSI questionnaire.
(Turkey) management systems (QMS).
[* The evidence level was based on the Joanna Briggs Institute (JBI) classification: https://joannabriggs.org/sites/default/files/2019-05/JBI-Levels-of-
evidence_2014_0.pdf; Pre-post-A = Pre-post Accreditation; AxNA = Accredited vs. Non-accredited; CCP - Cooperative Cardiovascular Project; AHA –
American Hospital Association, MEDPAR - Medicare Provider Analysis and Review; MARQuIS – Methods of Assessing Response to Quality Improvement
Strategies; IWS – Index of Work Satisfaction (validated Brazilian version); HCAHPS - Hospital Consumer Assessment of Healthcare Provider and Systems;
IMHO-84 – Inventory of Mental Health Organizations, 1984; QMSI - quality management system index; EFQM – European Foundation for Quality
Management]
Source: Elaborated by the authors.
Table 4. Accreditation Impact per study analyzed
Ref Comparison Design Healthcare Service Impact direction Quality Dimension
(Accrediting (Sample – comparison
institution) groups)
[26] AxNA NULL - The accreditation was not Efficiency: Financial aspects (costs
Accreditation associated with better quality measures. per patients), resource utilization
type/level (bed occupation) and human
(Joint Commission - Psychiatric care - 216 resources (percent of staff hours
JC; Health Care state psychiatric hospitals. provided by medical staff).
Financing
Administration -
HCFA)
[27] AxNA; Cardiology – AMI POSITIVE - Better treatment for AMI: Efficiency: hospital structure
Accreditation hospitalizations - 4,221 more likely to use aspirin, beta-blockers, (facilities) and human resources.
type/level public hospitals. and reperfusion therapy; Lower 30-day Effectiveness: mortality, % of
(Joint Commission – mortality. patients considered ideal candidates
JC) for a therapy who received the
therapy.
[28] AxNA; Acute care - 335 teaching POSITIVE - Better infection control Efficiency: Hospital structure and
Accreditation hospitals. infrastructure and performance at human resources.
type/level infection control programs. Safety: infection control.
(Japan Council for
Quality Health Care
– JCQHC)
[29] AxNA Emergency services at POSITIVE - Better treatment for AMI, Safety: evidence-based care.
(Joint Commission – critical access hospitals - Heart failure, pneumonia, and surgical
JC) 730 critical access infection prevention.
hospitals.
[30] AxNA Cardiology - 5,070 POSITIVE - Lower unadjusted and Effectiveness: LOS, mortality,
(Joint Commission – hospitals for cardiology. risk-adjusted in-hospital mortality, lower patient complications.
JC) 30-day mortality and lower
readmissions.
[31] AxNA Cardiology - 25 hospitals NULL - Null effect on patient's Patient centeredness: Patient
(Joint Commission – for cardiology. recommendation rate of a given hospital satisfaction and perceived quality of
JC) care.
[32] AxNA; General medical – POSITIVE - More evident quality and Safety: patient safety, clinical
Accreditation surgical services – safety structures and procedures. practice.
type/level community health care - Improvement in patient rights, feedback, Efficiency: human and physical
(Any established 89 hospitals. and privacy. resources.
programme for Patient Centeredness: Patient
health services rights, feedback and privacy.
accreditation)
[33] Pre-post-A Multispecialty inpatient POSITIVE - Improvement in Safety: evidence-based care.
(Korea Institute for and outpatient care - 5 identifying data, display parameters,
Accreditation of hospitals. scan length, spatial and contrast
Medical Image – resolution, window width and level,
KIAMI) optimal contrast enhancement, slice
thickness, and total score.
[34] AxNA Multispecialty inpatient NULL - Null effect on patient's Patient centeredness: patient
(Cooperation for care - 73 public and non- perception of quality of care. satisfaction.
Transparency and profit hospitals.
Quality in Hospitals
– KTQ)
[35] AxNA; Critical access care - POSITIVE - Better performance on 13 Safety: evidence-based care.
Accreditation 3,891 acute care and out of 16 standardized clinical
type/level critical access public performance measures and all summary
(Joint Commission - hospitals. score.
JC)
[36] AxNA Cardiology - 4,546 POSITIVE - Lower 30-day mortality, Effectiveness: mortality, LOS,
(Joint Commission - hospitals for cardiology. readmissions, and risk-standardized discharge.
JC) mortality
NULL - risk-standardized readmissions.
[37] Pre-post-A Multispecialty primary, POSITIVE - Lower: perioperative Effectiveness: mortality, blood
(Accreditation secondary, and tertiary mortality; neonatal mortality/100 transfusion reaction.
Canada International care - one University admissions; healthcare associated Safety: infections, adverse events,
– ACI) hospital. infections; blood transfusion reaction; processes of care, pressure ulcers.
unplanned returns to surgery; pressure
ulcers; number of occurrence. Higher:
rate of survival/100 patients.

[38] Pre-post-A Multispecialty - one acute POSITIVE - improvement maintained Safety: patient safety, clinical
(Joint Commission – care hospital. during the three-year accreditation cycle. practice.
JC) NEGATIVE - Drop in performance
immediately after the accreditation.
[39] AxNA; AMI, hip fracture, stroke, POSITIVE - clinical leadership; Efficiency: Human resources
Accreditation and obstetric deliveries - systems for patient safety; clinical (leadership), systems for patient
type/level. 73 hospitals. review. safety.
(Not specified) NULL - evidence-based patient care. Safety: evidence-based care.
[40] Pre-post-A Inpatient psychiatric POSITIVE - Reduction in the number Efficiency: material resources
(Accreditation services – one a Teaching PRN antipsychotic medications (medication administered).
Canada International Hospital. administered to psychiatric inpatients Safety: diagnosis prevalence rates.
– ACI) with no specified indications.
[41] Pre-post-A Surgical and internal POSITIVE - The proportion of Safety: Kinds of antibacterial in
(Joint Commission – medicine clinics – one antibacterial prescriptions and of outpatient pharmacy, Total number
JC) university-affiliated prescriptions containing restricted of prescriptions containing
hospital. antibacterial decreased, the overall antibacterial, Proportion of
proportion of oral versus all antibacterial prescriptions containing restricted

prescriptions increased and the antibacterial.
occurrence rate of drug-related problems Efficiency: Total expenditure on
decreased. The total expenditure on antibacterial for outpatients,
antibacterial for outpatients decreased Proportion of expenditure on
and the intervention program saved antibacterial and on IV antibacterial
money. relative to all medications.
NULL: Kinds of oral and IV
antibacterial in outpatient pharmacy,
total number of prescriptions, total
expenditure on antibacterial, proportion
of expenditure on antibacterial – and on
oral antibacterial – relative to all
medications, sum of defined daily doses
of antibacterial.
[42] Pre-post-A Multispecialty - one acute POSITIVE - improvement maintained
(Joint Commission – care hospital. during the three-year accreditation cycle. Safety: patient safety, clinical
JC) NULL - Drop in performance practice.
immediately after the accreditation.

[43] AxNA General surgical ICUs - 4 POSITIVE - Lower ICU return within Efficiency: Organizational aspects as
(Joint Commission – private hospitals. 24 hours of discharge and of annual staff staff turnover and completeness of
JC) turnover; increased completeness of medical records.
medical records.Ssavings of $593,000 Effectiveness: Readmissions, return
over 3 years. to surgery.
[44] AxNA Multispecialty - 33 public NULL - Null impact in performance Safety: evidence-based care.
(Joint Commission - non-psychiatric hospitals. measures for acute stroke, heart failure
JC or The Health or ulcer.
Quality Service)
[45] AxNA Tertiary care - 8 public POSITIVE: structure, outcome, and Patient centeredness: providers’
(Central Board of hospitals. overall quality of care. communication with patients
Accreditation for NULL: For assessments of access, Access: ease in accessing healthcare
Healthcare communication, and overall quality. services.
Institutions - Safety: general presence of effective
CBAHI) patient safety.
Effectiveness: quality of care.

[46] Pre-post-A Inpatient psychiatric POSITIVE - LOS in psychiatric Effectiveness: LOS.
(Accreditation services - one public inpatients.
Canada International teaching hospital.
– ACI)
[47] AxNA Not specified -11 public POSITIVE: quality of managerial Efficiency: quality of managerial
(National and private hospitals and functions. functions (e.g. processes
Accreditation one clinical analysis standardization, risks management,
Organization - ONA; laboratory. continuous improvement, strategic
Joint Commission planning).
International - JCI;
Canadian Council
on Healthcare
Services
Accreditation –
CCHSA)
[48] Pre-post-A; Acute care: stroke, heart POSITIVE - quality of hospital care. Safety: evidence-based care.
Accreditation failure, ulcer, diabetes, The positive trend prior to accreditation
type/level breast, and lung cancer - increased during accreditation and

(The Danish 25 public hospitals. continued post-accreditation, but it
Healthcare Quality began to plateau.
Programme for
hospitals)
[49] AxNA Not specified - 68 private POSITIVE - Compliance with OHS Efficiency: human (i.e. presence of
(Not specified) hospitals. accreditation standards: Better OHS OHS committee) and material
performance than non-accredited resources (i.e. equipment for
hospitals. ergonomic problems), organizational
aspects (i.e. job rotation, incentive
system).
[50] Pre-post-A Surgical, pulmonary, POSITIVE - Lower pressure ulcer Safety: infection and ulcer incidence.
(Not specified) neurology, neurosurgery, incidence average; Lower average LOS Effectiveness: LOS.
and general ICUs wards - NEGATIVE - Negative impact on
one teaching hospital. hospital infection.
[51] Pre-post-A Not specified - one public POSITIVE: A significant improvement Efficiency: nursing documentation.
(Joint Commission – university hospital. in the quality of nursing documentation
JC) was observed.

[52] Pre-post-A Mental health services - POSITIVE - Reduction in the number Efficiency: material resources
(Accreditation one public teaching of administered PRN benzodiazepines of (medication administered).
Canada International hospital. approximately 22% to psychiatric Safety: diagnosis prevalence rates.
– ACI) inpatients with no specified indications.
[53] Pre-post-A Not specified - 3 public POSITIVE - Improvements in the Safety: Infection rates.
(Central Board for hospitals. procedures and lower infection rates. Efficiency: Human resources.
Accreditation of NULL - Null impact on mortality and Effectiveness: Mortality, LOS.
Healthcare LOS.
Institutions –
CBAHI)
[54] Pre-post-A Non-psychiatric hospitals NEGATIVE: Processes related to heart Effectiveness: treatment;
(The Danish - 25 hospitals. failure, breast cancer and diagnostics diagnostics; secondary prevention
Healthcare Quality appeared to be negatively affected by and patient monitoring.
Program – DDKM) accreditation.
POSITIVE: processes related to
diabetes and diagnostics with an
unsatisfactory level of quality were
positively affected by accreditation.

[55] Pre-post-A Tertiary care - 2 tertiary POSITIVE - Shorter length of waiting Effectiveness: mortality, LOS.
(Not specified) hospitals. for the first scheduled health check at Timeliness: waiting time for a health
the institution and for the first scheduled check or surgical check.
surgical check; Lower rate of patients
with decubitus and of hospital days per
patient with AMI.
NULL - mortality rate; mortality rate
within 48 hours; average rate of hospital
days per patient at institution level.
[6] AxNA; Medical-surgical NULL - readmissions at 30 days for Effectiveness: mortality,
Accreditation multispecialty services - medical or surgical conditions, 30-day readmissions.
type/level 4,400 acute and critical mortality for medical or surgical Patient centeredness: patient
(Joint Commission – care hospitals. conditions, mortality for surgical experience.
JC) conditions and patient experience.

[56] Pre-post-A Surgical services - one POSITIVE - Higher pre-anesthesia time Timeliness: surgery, anesthesia, etc.
(Joint Commission – private teaching hospital. and lower anesthesia induction time.
JC) NULL - total procedure/surgery time.
[57] Pre-post-A Acute care - one public POSITIVE - Higher patient experience. Effectiveness: patient outcomes.
(Australian Council teaching hospital. NULL - Null effect on patient outcome. Patient centeredness: patient
on Healthcare experience.
Standards – ACHS)
[58] AxNA Adult ICUs (general, POSITIVE - Higher job satisfaction Efficiency: Human resources
(Not specified) coronary, cardiologic) and score of nursing workers. (professional satisfaction).
infant ICUs (neonatal and
pediatric) - 3 hospitals.
[59] AxNA Not specified - 346 NULL: bed occupancy rate, average Effectiveness: LOS; mortality.
(Joint Commission – hospitals. LOS, turnover interval, gross mortality Efficiency: bed occupancy rate, bed
JC) rate, and net mortality rate. turnover.

[60] AxNA Not specified - 350 POSITIVE: Formal protocols for Efficiency: organizational aspects.
(Joint Commission – hospitals. medication and patient handling, Quality Safety: protocols for infection
JC and ISO 9001) policy documents, Quality monitoring, control.
professionals` training, Care processes, Effectiveness: care process.
professionals` performance, feedback of Patient centeredness: patient
patient experiences. experience.
NULL: Formal protocols for infection
control.
.
[AMI = Acute myocardial infarction; CPR – Cardiopulmonary resuscitation CT = Computerized tomography; PRN = pro re nata; LOS = Length of Stay; ICU =
Intensive Care Unit; OHS - Occupational Health and Safety]
Table 5. Accreditation Impact on Healthcare Quality Dimensions (number of articles and %)
Positive & Null Negative &
Dimension Positive Positive & Null Negative TOTAL
Negative Null
12 (67%)
1 (5%) 2 (11%) 3 (17%)
Safety [28,29,32,33,35,37,40, 0 (0%) 0 (0%)
[41] [38, 50] [39, 44, 60] 18 (100%)
42,55,48,52,53]
13 (81%)
1 (6%) 2 (13%)
Efficiency [27,28,32,39,40,43,47, 0 (0%) 0 (0%) 0 (0%) 16 (100%)
[41] [26,59]
49,51,52, 53,58,60]
8 (53%)
2 (13%) 1 (7%) 4 (27%)
Effectiveness [27,30,37,43,45,46,50, 0 (0%) 0 (0%) 15 (100%)
[36,55] [54] [53,6,57, 59]
60]
Patient- 4 (57%)
3 (43%) [32,57,60] 0 (0%) 0 (0%) 0 (0%) 0 (0%) 7 (100%)
centeredness [6,31,34, 45]
Timeliness 1 (50%) [55] 1 (50%) [56] 0 (0%) 0 (0%) 0 (0%) 0 (0%) 2 (100%)
0 (0%) 0 (0%) 1
Access 0 (0%) 1 (100%) [45] 0 (0%) 0 (0%)
(100%)
Equity 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Supplementary material. Quality Assessment of Selected studies
Author, year [ref] Detection Performance
Level of Data sources and Overall quality
bias bias
evidence reporting bias assessment
Hadley and McGurrin, 1988 [26] Low Medium High High Low
Chen et al., 2003 [27] Low Medium Low Low Medium
Sekimoto et al., 2008 [28] Low Medium Medium Medium Medium
Lutfiyya et al., 2009 [29] Low Low High Medium Medium
Lichtman et al., 2009 [30] Low Low Low Medium Medium
Sack et al., 2010 [31] Low Medium Low Low Medium
Shaw et al., 2010 [32] Low High Medium Medium Low
Kim et al., 2010 [33] Low High High Medium Low
Sack et al., 2011 [34] Low Medium Low Low Medium
Schmaltz et al., 2011 [35] Low Low Low Medium Medium
Lichtman et al., 2011 [36] Low Medium Medium Medium Medium
Al-Awa et al., 2011 [37] Low Low High Low Medium
Devkaran and O’Farrell, 2014 [38] Medium Medium High Low Medium
Shaw et al., 2014 [39] Low High Medium Low Medium

Al-Sughayir, 2014 [40] Medium Medium Medium Low Medium
Song, Li, and Zhou, 2014 [41] Medium Medium High High Low
Devkaran and O’Farrell, 2015 [42] Medium High High Medium Low
Halasa et al., 2015 [43] Low Medium Low Low Medium
Bogh et al., 2015 [44] Low Low Low Low High
Aboshaiqah, Alonazi and Patalagsa, 2016 [45] Low Medium High Low Medium
Al-Sughayir, 2016 [46] Medium Low Medium High Medium
Berssaneti et al., 2016 [47] Low Medium High Low Medium
Bogh et al., 2016 [48] High Low Low Medium High
Habib et al., 2016 [49] Low High Medium Medium Low
Janati et al., 2016 [50] High Low High Low High
Nomura, Silva and Almeida, 2016 [51] Medium High High High Low
Al-Sughayir, 2017 [52] Low Low Medium Low Medium
Almasabi and Thomas, 2017 [53] Low Medium High Low Medium
Bogh et al., 2017 [54] Medium Medium High Low Medium
Markovic-Petrovic et al., 2018 [55] Medium Low High High Low
Lam et al., 2018 [6] Low Low Low Low High
Inomata et al., 2018 [56] Low Medium Medium Medium Medium

Andres et al., 2019 [57] Low Low Low Low High
Oliveira et al., 2019 [58] Low Medium High Low Medium
Wardhani et al., 2019 [59] Low Medium High Low Medium
Yildiz et al., 2019 [60] Low Low Low Low High
[Low level of evidence is attributed to observational designs, medium is attributed to quasi-experimental designs and high to experimental designs (High: 1,
Medium: 0, Low: -1); A high risk of detection bias exists when a variety of indicators are used to evaluate the impact of accreditation, but the validity and
reliability of measures is debatable or unjustifiable (Low: 1, Medium: 0, High: -1); A high risk of performance bias exists when accreditation effects are not
controlled for confounding variables (Low: 1, Medium: 0, High: -1); A high risk in the reporting and data sources is attributed when the study presents limited to
no information on limitations, when there is no use of complementary data sources (e.g. primary and secondary, quantitative and qualitative data), or when there
is limited to no data triangulation (Low: 1, Medium: 0, High: -1); Overall quality assessment – High quality: total score of 4 to 2; Medium quality: Total score
of -1 to 1; Low quality: Total score of -2 to -4] - Source: Based on Hinchcliff et al [16]
Supplementary Material. PRISMA 2009 checklist
Reported on
Section/topic # Checklist item
page #
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both. 1
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; 1
study eligibility criteria, participants, and interventions; study appraisal and synthesis methods;
results; limitations; conclusions and implications of key findings; systematic review registration
number.
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known. 1-2
Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, 2
interventions, comparisons, outcomes, and study design (PICOS).
METHODS
Protocol and 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if NA
registration available, provide registration information including registration number.
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., 4
years considered, language, publication status) used as criteria for eligibility, giving rationale.
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study 3
authors to identify additional studies) in the search and date last searched.
Search 8 Present full electronic search strategy for at least one database, including any limits used, such 4
that it could be repeated.
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, 4-5
and, if applicable, included in the meta-analysis).
Data collection 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in 5
process duplicate) and any processes for obtaining and confirming data from investigators.
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any 4
assumptions and simplifications made.
Risk of bias in 12 Describe methods used for assessing risk of bias of individual studies (including specification Supplementary
individual studies of whether this was done at the study or outcome level), and how this information is to be used material
in any data synthesis.
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). NA
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including NA
measures of consistency (e.g., I2) for each meta-analysis.

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A SYSTEMATIC REVIEW OF HOSPITAL ACCREDITATION IMPACT ON

HEALTHCARE QUALITY DIMENSIONS

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Marina Martins Siqueira

Ana Maria Malik

Running Title: Hospital Accreditation Impact.

Word count for the abstract: 249 words.

Word count for the text of the manuscript: 2,933

DIMENSIONS: A SYSTEMATIC REVIEW

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indicators, as classified into seven healthcare quality dimensions.

examine the impact of hospital accreditation on healthcare quality indicators.

following criteria: Population - all types of hospitals; Intervention - hospital

accreditation; Comparison – quantitative method applied to compare accredited vs. non-

studies were included in this review.

Conclusion. Mainly due to the methodological shortcomings, the positive impact of

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dimensions, Healthcare quality indicators.

including: safety, patient-centeredness, timeliness, equity, access, efficiency and effectiveness

[2,3]. However, accurately assessing HQ is difficult, as there is a lack of formal systems to

Hospital accreditation programs, defined as the “systematic assessment of hospitals against

structure, usually comprising non-governmental and non-profit organizations. The process

and implementation of specified requirements. It also comprises survey visits by a

multidisciplinary healthcare team, leading to a detailed report of identified areas of improvement

and the next cycle of follow-up visits [8, 9].

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--------------------------- TABLE 1 ---------------------------

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search to better capture the accreditation impact on hospitals.

--------------------------- TABLE 2 ---------------------------

hospitals; Intervention – hospital accreditation; Comparison – pre-post-A or AxNA

journals impact factor.

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(differences without statistical significance), positive, or negative (differences with statistical

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by BMC Health Services Research, with four studies (4/36;11%).

Twenty articles (20/36;56%) compare AxNA hospitals, and 16 (16/36;44%) compare a

(17/36;47%), followed by Accreditation Canada International – ACI (4/36;11%). Five studies

international accreditations. There are studies conducted in public (11/36;30%), private

study varies from 1 to 5,070.

Regarding the methodology, most articles (33/36;92%) adopt a purely quantitative

regression models (15/36;42%), followed by Chi-square (11/36;30%), ANOVA (9/36;25%),

Mann–Whitney (9/36;25%), and Students’ t-test (8/36;22%). Thirty-four articles (34/36;94%)

adopted a 0.05 significance threshold.

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approaching complex and multifarious phenomenon such as hospital accreditation [25]. As

--------------------------- TABLE 3 ---------------------------

3.2 Accreditation Impact

negative impact (see Table 4).

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different accreditations or did not specify the institution.

--------------------------- TABLE 4 ---------------------------

accreditation impact on equity. (Table 5).

--------------------------- TABLE 5 ---------------------------

Most articles (12/18;67%) indicate a positive impact of accreditation on safety indicators

impact on this dimension [39, 44, 60].

Sixteen articles analyze the impact of accreditation on efficiency. Thirteen studies

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negative impact of accreditation on non-psychiatric hospitals in Denmark. The effectiveness

shown to be negatively affected by accreditation.

Seven articles analyze the impact of accreditation on patient-centeredness, and in four of

effect on total procedure/surgery time.

should ideally be pursued by hospital accreditation interventions.