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Nursing Perception Towards Impact of JCI Accreditation and Quality of Care in

a Tertiary Care Hospital, Central Saudi Arabia

Article  in  International Journal of Medical Sciences · March 2014

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 International Journal of Medicine and Medical Sciences, ISSN:2051-5731, Vol.47, Issue.1 1447
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Nursing Perception Towards Impact of JCI

Accreditation and Quality of Care in a Tertiary
Care Hospital, Central Saudi Arabia
Mostafa A. Abolfotouh
King Abdullah International Medical Research Center (KAIMRC),
King Saud bin-Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
Mohamed AlKelya
King Abdullah International Medical Research Center (KAIMRC),
King Saud bin-Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
Nawal AbuKhalid
King Abdullah International Medical Research Center (KAIMRC),
King Saud bin-Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
Mahmoud Salam
King Abdullah International Medical Research Center (KAIMRC),
King Saud bin-Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
Ahmed Alamry
Quality management department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Corresponding Author Email: mabolfotouh@gmail.com
ABSTRACT
Nurses‟ perception to accreditation impact was a
Background. Hospital accreditation indicates meeting the significant predictor of perception of QHC (p<0.001).
highest international standards and requirements in the Higher QHC was more likely to be perceived by the less
health care industry .Aims of this study are: 1) to assess educated (p<0.001), and less experienced (p=0.047)
nurses‟ perception to JCI accreditation impact, 2) to assess nurses, and nurses with direct patient care (p=0.041).
nurses‟ perception to quality of health care (QHC), and 3)
to identify the predictive factors for perception to Conclusion. This study addresses the impact of perception
accreditation and QHC at King Abdulaziz Medical City to accreditation on other hospital duties while preparing
(KAMC), Riyadh, Saudi Arabia. for accreditation such as the continuity and quality of
patient care during the preparation process. Strategies are
Methods. An anonymous electronic-based survey of 476 required to reinforce the way accreditation might lead to
nursing personnel at KAMC was conducted, using two improved quality of care, strengthen leadership, culture
previously validated tools of different domains, to assess and climate, and how these factors in turn might mediate
accreditation impact and QHC, as perceived by nurses. accreditation performance.
Data on demographic characteristics such as; age, gender,
nationality, education, job position, and specialty were 1. INTRODUCTION
collected. A scoring system was applied and percentage
Any health care organization accredited indicates that it
mean scores (PMS) were calculated for each domain, and
has met the highest international standards and
for overall perceptions. Descriptive and analytic statistics
requirements in health care. It is recognition of the
were applied. Logistic regression analysis was conducted
organization worldwide and a seal of approval for its high
to identify the significant predictors of nurses‟ perception
quality of patient care [1]. Joint Commission International
to accreditation and QHC. Significance limits were set at P
(JCI) is the international division of the Joint Commission
<0.05.
Resources (JCR) and the Joint Commission [2]. JCI
Results. Of 751 nursing personnel surveyed, 476 (60%) mission is to advise, help and continuously improve the
responded. Their mean of age was 40.7+9.2 years, the international health organizations, health ministries, and
majority were females 426 (89.5%), expatriates (95%), public health agencies to reach the highest standards of
BSN graduate (72%), with mean 13.04+9.6 years of work safety and quality in patient care. JCI provides
experience, with medical (62%), surgical (31%), and organization with education, consultation services,
administrative /education (7%) specialties. Overall international accreditation, and certification, while still
percentage mean scores (PMS) for perception of accommodating their own religious, cultural and legal
accreditation impact was 71.13±17.85, reflecting neutral factors [1-2].
perception, and 66.87±17.71 for perception to QHC,
As a recognized leader in the world health care, JCI has
reflecting an average QHC. Older (p=0.043) and less
worked with health care organizations, ministries of
educated nurses (p=0.042) were significantly more likely
health, and global organizations in over 80 countries [3].
to report positive perception to accreditation impact.
Since 1999, JCI has accredited more than 140 hospitals in

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 International Journal of Medicine and Medical Sciences, ISSN:2051-5731, Vol.47, Issue.1
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27 countries in the Middle East, Asia, Europe and South
America [4]. The International Society for Quality in
Health Care (ISQua) accredited the JCI in September
2007, which means that the JCI met the highest
international standards for accreditation entities [5].
In 2008, a systematic review of the accreditation in
literature reviewed and analyzed 66 articles that
emphasized on the impact or effectiveness of accreditation
programs in health systems and customer‟s perception [6].
In Egypt, the effect of accreditation on patients‟ and
providers‟ satisfaction in non-governmental health units
was studied [7]. This study compared 30 accredited non-
governmental health units to 30 unaccredited units It
concluded that accredited health centers showed higher
patient satisfaction compared to non-accredited health
units [7]. In Lebanon, a cross-sectional survey was
launched on hospitals that successfully passed both
national and international accreditation surveys [8], to
assess the perceived impact of accreditation on quality of
care from the health care professionals‟ point of view,
specifically nurses. The results revealed that nurses
perceived improvement in quality as a result of
accreditation [8].
National Guard Health Affairs (NGHA) constitutes of a
dynamic interactive culture of multidisciplinary
professions that focus on Quality. The nature of service
provided by this medical center circum navigates a
sensitive issue which is health that bears no space for
errors, malpractice, or negligence. These facts have urged
the management to set journeys towards excellence that
would reflect a gold standard of the services provided to
the community of National Guard. Unfortunately,
although NGHA passed two accreditation surveys in the
past few years [9], no studies have been launched among
patients and health care workers to inspect their perception
toward this accreditation. Therefore, the aim of this study
was to study the nurses‟ perception to JCI accreditation at
KAMC, Riyadh, Saudi Arabia, through the following: 1)
to assess nurses‟ perception to JCI accreditation impact, 2)
to assess nurses‟ perception to quality of health care
(QHC), and 3) to identify the predictive factors for
perception to accreditation and QHC.
2. METHODS
2.1 Study design
A cross-sectional electronic survey of nursing service
personnel at KAMC.
2.2 Study setting
King Abdulaziz medical city (KAMC) of the National
Guard Health Affairs (NGHA), Riyadh is a distinguished
healthcare provider. At KAMC, the bed capacity is beyond
1000 beds providing care to more than 500,000 patients
annually. Because of the importance of healthcare quality
to NGHA on an international scope, NGHA has passed the
requirements for accreditation under the JCI standards
with excellent performance in December 2006; this
accreditation included all of NGHA hospitals (9). In
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1448
December 2009, NGHA achieved re-accreditation in its
hospitals in the three regions (central, eastern and western)
of Saudi Arabia [5], and The NGHA earned the JCI
„Gold Seal of Approval‟ with excellent results [9].At the
time of this survey (August, 2011), NGHA had been
preparing for its third year inspection for the re-
accreditation by JCI.
2.3 Study participants and sampling
technique
At KAMC Riyadh, the nursing service personnel including
professional nurses, para-nursing, auxiliary and support
staff are estimated to be 4,000. Nurses enrolled in the
study were all full time employees and holders of a license
from the Saudi Commission for Health Specialties. Part
time nurses and nursing students were excluded from the
study.
Based on the assumption of 50% favorable perception of
nurses [8], and with a margin of error of 5%, and 95%
confidence limits, the sample size was estimated to be 386.
To compensate for an average of 25% non-response, a
sample size of 584 was adopted. However, to achieve
more rigorous results and more representative sample of
the nursing community, a consecutive sampling technique
was used.
2.4 Data Collection
The study was based on an anonymous, electronic, English
based survey, disseminated to all nursing personnel via a
link attached to a mass e-mail distribution. Previously
validated tools were used in this survey [10, 11], to assess
the accreditation impact [10] and the quality of health care
[11] as perceived by nurses at KAMC.
I. Perceived Impact of hospital Accreditation (12
statements) [10]:
This tool incorporates two domains: (a) Degree of staff
involvement domain (5 statements), and (b) Benefits of
accreditation domain (7 statements). Issues such as
individual participation, awareness on recommendations,
and opportunities to improve were questioned. Perception
of nurses regarding benefits of accreditation on patient
services, job motivation, usage of internal resources, and
collaboration was asked. This tool questions whether
accreditation enables the institution to better respond to
public needs and is considered as a valuable tool to
collaborate with other health care facilities.
Nurses responded to each of the 12 statements on a 5-point
Likert scale, ranging from Strongly disagree (0 point) to
Strongly agree (4 points). Responses on each of the
domain were converted to percentage mean scores (PMS).
Scores below 50 were accounted to have negative
perception, scores between 50-75 show neutral perception,
and scores above 75 were accounted to have positive
perception.
II. Quality of Health Care ( 37 statements) [11]:
This tool is composed of six domains:
 International Journal of Medicine and Medical Sciences, ISSN:2051-5731, Vol.47, Issue.1
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1. Quality (4 statements): This domain investigated
nurses‟ perception of the institutions‟ improvement in
services regarding the quality of care and patient
satisfaction. A number of services were stated as examples
such as medical, surgical, obstetrics, pharmacy, lab, etc.
Nurses were asked on the quality of services affecting
them such as finance and human resources.
2. Leadership, commitment and support (8 statements):
Top managerial levels were involved in this domain of
perception. Nurses were questioned if a clear vision and
leadership exists in their institution regarding the quality
of care and services provided. Being the driving force
behind quality improvement, nurses were asked if top
management allocated resources for such activities and if
nurses‟ participation was appreciated. Nurses were asked
regarding change management activities based on
suggestions and accreditation results.
3. Strategic quality planning (9 statements): In this
domain, nurses were asked if they were given adequate
time to plan and set the goals for the accreditation survey.
Quality objectives of the institution were asked to be
identified and how nurses are involved in developing plans
to meet these objectives. Properly setting priorities in
quality improvement by middle management was
questioned. Perception of nurses regarding patients‟
expectations and needs was also questioned in this
domain.
4. Human resources utilization (5 statements): The two
main components of this domain were education and
training versus reward and recognition. Nurses were
questioned if they received continuous education and
training to improve job skills and performance. Nurses
were also asked if rewards and recognition were served.
Further questions regarding interdepartmental cooperation
within an effective system were present so that
suggestions to management help to improve quality of
services provided by the institution.
5. Quality mangments (6 statements): Nurses were asked if
their institution viewed quality as a continuous search for
ways to improve. Perception regarding the effectiveness of
policies and implementation of new services was
investigated. Quality check of services and equipment was
questioned as seen by the nurses who responded to the
degree of abidance with the quality requirements.
6. Usage of data (5 statements): Nursing perception
concerning records of patient complaints was questioned.
Identifying expectations, analyzing patient complaint and
communicating them with designated personnel tend to
improve services and satisfaction.
Nurses responded to each of the statements on a 5-point
Likert scale, ranging from Strongly disagree (0 point) to
Strongly agree (4 points). Responses on each of the
domain were converted to PMS. Scores below 50 were
accounted to perception of low QHC level, scores between
50-75 show perception of an average QHC level, and
scores above 75 were accounted to have perception of high
QHC level.
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1449
These tools are cross culturally valid being previously
utilized in a study conducted through out multiple health
care facilities in Lebanon [8]. Editing of some terms was
done to customize the survey based on the study setting
and familiarity. Later, a pilot study on randomly selected
20 participants was conducted to further assess the tool for
inter-rater reliability which yielded a Cronbach's α of
0.956.
Nurses were requested to note demographic and personal
data such as their gender, age, and nationality. Job related
information such as years of experience, area of specialty,
level of education, and current job position was collected.
Ethical considerations:
The survey was introduced to the participants through an
online cover page, explaining the aim of the study.
Participation in the study was voluntary and confidential
assuring that participants‟ feedback would not affect their
work evaluation, work status, and salary. Collection of
surveys was performed by a data registrar so that no mail
address is traced by the study investigators. Nurses who
consented to participate in the study clicked a button and
proceeded to the survey. This study was approved by the
IRB of the National Guard Health Affairs, Riyadh, Saudi
Arabia (Ref. RR11/139).
2.5 Data analysis
The Statistical Package for the Social Sciences (SPSS
version 17.0; IBM Corporation, Armonk, NY, USA) was
used for data analysis. Categorical data of
sociodemograhics were illustrated in frequency and
percentages. The arithmetic mean was used as a summary
statistic for quantitative data. The standard deviation was
used as a measure of dispersion. The chi square test was
used as the test of significance to compare categorical
data. Student‟s t-test was used as a test of significance to
compare numerical data. Logistic regression analyses were
used to determine the significant predictors of the
favorable nurses‟ perception towards accreditation. For all
statistical analyses, a P-value ≤ 0.05 was considered to be
significant.
3. RESULTS
3.1 Part I: Demographic Data
In our study, 756 nurses were surveyed out of which 476
(response rate = 63.4%) responded by completely
answering all the statements. The majority of nurses were
females (426, 89%); their mean of age was 40.7+9.2 years,
ranging between 23-65 years. Foreign nurses who
participated in this study originated mainly from far East
Asia and neighboring Arabian countries (452, 95%).
Levels of education varied between Bachelor degrees
(342, 71.8%), under graduate diplomas (86, 18.1%), and
post graduates with Master or PHD degrees (48, 10.1%).
Nurses occupying managerial positions were 96 (20.2%)
ranging from directors, supervisors, mid/lower
management and education. Direct patient care nurses
were 380 (79.8%) working in various specialty wards
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categorized into medical (299, 62.8%), surgical (146, years, with the majority (242, 50.8%) being seniors having
30.7%), and administrative/education (31, 6.5%). Mean of more than 10 years of experience in nursing. Table.1
years of experience was 13.1+9.6, ranging between 1 – 41

Table 1: Nurses‟ demographic and job characteristics in the study sample.

Personal Characteristics n (%)

Gender
Male 50 (10.5)
Female 426 (89.5)

Nationality
Saudi 24 (5.0)
Non- Saudi 452 (95.0)

Age
< 30 years 64 (13.4)
30-45 years 275 (57.8)
> 45 years 137 (28.8)
x+SD (range) 40.7+9.2 (23-65)

Level of education

Technical 86 (18.1)
Bachelor 342 (71.8)
MSN/PHD 48 (10.1)

Years of experience
< 5 years 105 (22.1)
5 – 10 years 129 (27.1)
> 10 years 242 (50.8)
x+SD (range) 13.1+9.6 (1-41)

Position
Managerial 96 (20.2)
Direct patient care 380 (79.8)

Area of specialty
Medical 299 (62.8)
Surgical 146 (30.7)
Administrative/Edu 31 (6.5)
cation

3.2 Part II- Perception of the impact of hospital
accreditation
Figure 1 shows the percentage mean score (PMS) of
71.13±17.85 for nurses‟ perception to hospital
accreditation impact, reflecting neutral perception. This
PMS was 69.97±18.43 & 71.95±20.09 for staff
involvement domain and benefits of accreditation domain
respectively. With regard to staff involvement in
accreditation process as perceived by nurses, the majority
reported that important changes during the preparation for
the last survey (68.9%) and those they participated in its
implementation at the NGHA (73.8%), and in their own
sections (73.7%). Table 2.

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Table 2. Nurses‟ perception towards the impact of hospital accreditation domains.

Strongly Disagree Neutral Agree Strongly

Accreditation impact Domains disagree agree
n (%) n (%) n (%) n (%) n (%)
A) Staff involvement:
1) During the preparation of the last survey,
14(2.9) 22(4.7) 112(23.5) 271(56.9) 57(12.0)
important changes were implemented at
NGHA.
2) You participated in the implementations of
14(2.9) 14(2.9) 98(20.7) 277(58.2) 73(15.3)
these changes at NGHA.
3) You are aware of the recommendation
13(2.7) 29(6.1) 83(17.4) 275(57.8) 76 (16.0)
made to your section since the last survey.
4) These recommendations are opportunities
8 (1.7) 9 (1.9) 89(18.7) 288(60.5) 82(17.2)
to implement important changes at NGHA.
5) You participated in the changes that
resulted from these recommendations. 10(2.1) 17(3.6) 98(20.6) 279(58.6) 72(15.1)

B) Benefits of accreditation:
1) Accreditation enables the improvements of
patient care at NGHA. 12(2.6) 14(2.9) 62(13.0) 26(55.0) 126(26.5)

2) Accreditation enables the motivation of

staff through team work and collaboration. 17(3.5) 24(5.0) 75(15.8) 243(51.1) 117(24.6)

3) Accreditation enables the development of

values shared by all professional at NGHA 14(2.9) 21(4.4) 79(16.6) 255(53.6) 107(22.5)

4) Accreditation enables NGHA to better use

its internal resources (e.g. finances, people,
time and equipments). 14(2.9) 35(7.4) 102(21.4) 237(49.8) 88(18.5)

5) Accreditation enables NGHA to better

respond to the public needs. 13(2.7) 27(5.7) 90(18.9) 257(54.0) 89(18.7)

6) Accreditation contributes to the

development of collaboration with partners
(other hospitals, diverse hospitals, privet 12(2.6) 18(3.8) 10 (21.6) 250(52.5) 93(19.5)
clinics, etc.) in the health care system.

7) Accreditation is a valuable tool to

13(2.7) 12(2.5) 63(13.2) 253(53.2) 135(28.4)
implement changes at NGHA.

With regard to benefits of accreditation as perceived by
nurses, the majority of nurses agreed that accreditation
enables the improvements of patient care at NGHA
(81.5%), and is a valuable tool to implement changes
(81.6). However, only 68.3% of nurses agreed that it
enables NGHA to better use its internal resources.
Table 3 shows that, for more than one-half (52.3%) of
nurses, perception to hospital accreditation impact was
positive. However, those constituted a significantly higher
proportion of non-Saudi than Saudi nurses (53.1% vs.
37.5%, p=0.02). Meanwhile, the PMS of nurses
perception was significantly higher among nurses of
Bachelor degree or less education than among those of
higher education (71.76 vs. 65.45, p=0.02). However,
after adjustment for all nurses‟ personal characteristics,
older (p=0.043) and less educated nurses (p=0.042) were
significantly more likely to report higher PMS of
perception to accreditation impact.

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Table 3. Nurses‟ perception to accreditation impact according to some personal characteristics

Characteristics Perception to accreditation impact

Negative Neutral Positive % mean score
(n=44, %9.2) (n=183, 38.4%) (n=249, 52.3%) ( x ±SD)
Gender
Male 8 (16.0) 18 (36.0) 24 (48.0) 68.04+23.18
Female 36 (8.5) 165 (38.7) 225 (52.8) 71.48+17.11

χ2 =3.044, p=0.218 t =1.019, p=0.313,

p adj.=0.564
Nationality
Saudi 6 (25.0) 9 (37.5) 9 (37.5) 61.80+24.54
Non- Saudi 38 (8.4) 174 (38.5) 240 (53.1) 71.62+17.31
χ2 =7.854, p=0.02* t =-2.64, p=0.065,
p adj.=0.08
Age
< 30 years 10 (15.6) 22 (34.4) 32 (50.0) 66.73+22.30
30-45 years 19 (6.9) 113 (41.1) 143 (52.0) 71.84+15.98
> 45 years 15 (10.9) 48 (35.0) 74 (54.1) 71.74+18.88
x+SD : 40.7+9.2
χ2 =6.209, p=0.184 F=2.25,df=2, p=0.106,
p adj.=0.043*
Level
of education
Tech/BSN 35 (8.2) 167 (39.0) 226 (52.8) 71.76+17.48
MSN/PHD 9 (18.8) 16 (33.3) 23 (47.9) 65.45+20.16
χ2=5.779, p=0.056 t=2.334, p=0.02*,
p adj.=0.042*
Years of experience
< 5 years
5 – 10 years 10 (9.5) 39 (37.1) 56 (53.4) 69.20+20.15
> 10 years 15 (11.6) 46 (35.7 68 (52.7) 70.63+17.63
x+SD : 13.1+9.6 19 (7.9) 98 (40.5) 125 (51.6) 72.21+17.84
χ2= 1.926, p=0.749 F=1.110,df=2, p=0.330,
p adj.=0.250
Position
Managerial 9 (9.4) 44 (45.8) 43 (44.8) 70.63+19.43
Direct patient care 35 (9.2) 139 (36.6) 206 (54.2) 71.25+17.44
χ2= 3.009, p=0.222 t =-0.300, p=0.764,
p adj.=0.884

3.3 Part III- Perceived level of Quality of
Health Care
Figure 1 shows nurses‟ perception percent mean score
(PMS) of 66.87±17.71 to quality of health care (QHC),
reflecting perception of an average level of QHC.
However, it varied with the different domains of QHC as
follows: perception related to quality (66.11 ± 17.76),
leadership, commitment and support (65.89.0 ± 19.7),
strategic quality planning (70.23 ± 17.72), human
resources utilization (61.15 ± 20.86), quality management
(70.76±16.64) and usage of data (64.07±20.58).

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 International Journal of Medicine and Medical Sciences, ISSN:2051-5731, Vol.47, Issue.1 1453
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Figure 1. Nurse's perception of hospital accreditation impact and of quality of health care at King Abdulaziz Medical
City, Riyadh, Saudi Arabia.

Table 4 shows that with regard to quality domain, the
majority of nurses agreed that there has been steady
improvement in the quality of patient satisfaction.
Meanwhile, two-thirds (68.5%) of nurses reported steady
improvement in the quality of services provided to
patients. These improvements were reported for services
provided by administration and by clinical support of
departments by 74.4% and 50.7% of nurses respectively.
The majority of nurses agreed that senior executives have
articulated a clear vision for the improvement of quality of
care and services at NGHA, yet only 55.4% agreed those
seniors allocate available resources to improve this
quality.

Table 4. Response of Nurses to perception to quality of health care (QHC) domains.

Strongly Disagree Neutral Agree Strongly

QHC Domains disagree agree
n (%) n (%) n (%) n (%) n (%)
Domain 1: Quality
1) Over the past 5 years, NGHA has
10(2.1) 18(3.8) 87(18.3) 289(60.7) 72(15.1)
shown a steady improvement in the
quality of patient satisfaction.
2) NGHA has shown improvement in
the quality of services provided by
8(1.7) 24(5.0) 90(18.9) 296(62.2) 58(12.2)
administration (finance, human
resources, etc).
3) NGHA has shown steady
improvement in the quality of services
provided to patients (e.g. medical, 9(1.9) 33(6.9) 108(22.7) 280(58.8) 45(9.7)
surgical, obstetric and pediatric
patients).
4) NGHA has shown steady
improvement in the quality of services
provided by clinical support of 34(7.1) 69(14.5) 132(27.7) 206(43.3) 35(7.4)
departments such as laboratory,
pharmacy and radiology.

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Domain 2: Leadership,
commitment and support
1) Senior hospital executives
12(2.6) 22(4.5) 84(17.6) 283(59.5) 75(15.8)
have articulated a clear vision for
improving the quality of care
and services at NGHA.
2) They provide highly visible
leadership in maintaining an
21(4.4) 34(7.1) 102(21.4) 257(54.0) 62(13.1)
environment that supports
quality improvement at NGHA
3) The top management is a
primary driving force behind
17(3.6) 37(7.8) 117(24.6) 239(50.2) 66(13.8)
quality improvements efforts at
NGHA
4) Senior hospital executives
allocate available resources (e.g.
finance, people, time, and 20(4.2) 51(10.7) 141(29.6) 220(46.3) 44(9.2)
equipments) to improve quality
at NGHA
5) They consistently participate
in activities to improve the
14(2.9) 30(6.4) 109(22.9) 271(56.9) 52(10.9)
quality of care and services at
NGHA
6) They have demonstrated an
ability to manage the change
(e.g. organizational,
18(3.8) 23(4.8) 111(23.3) 273(57.4) 51(10.7)
technological) needed to
improve the quality and services
at NGHA
7) Senior hospital executives
have started to act on
suggestions to improve the 19(4.0) 39(8.2) 113(23.7) 257(54.0) 48(10.1)
quality and of care and services
at NGHA
8) Based on accreditation results,
senior hospital executives have a
thorough understanding of how 19(4.0) 26(5.5) 118(24.8) 259(54.4) 54(11.3)
to improve the quality of care
and services at NGHA
Domain 3: Strategic Quality
Planning
1) Nurses are given adequate 16(3.4) 35(7.4) 92(19.3) 261(54.8) 72(15.1)
time to plan for the accreditation
survey at NGHA.
2) Each department at NGHA
maintains specific goals to 8(1.6) 17(3.6) 66(13.9) 306(64.3) 79(16.6)
improve the quality.
3) NGHA‟s quality
improvements goals are known 12(2.5) 16(3.4) 55(11.6) 302(63.4) 91(19.1)
throughout your unit.
4) Nurses are involved in
developing plans for improving 20(4.2) 27(5.6) 68(14.3) 266(55.9) 95(20.0)
quality at NGHA.
5) Middle managers (e.g. nurse
heads, director of nursing or
clinical specialist) play a key 14(2.9) 17(3.6) 78(16.4) 261(54.8) 106(22.3)
role in setting priorities for
quality improvement at NGHA

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6) Nurses play a key role in

setting priorities for quality 16(3.4) 16(3.4) 62(13.0) 236(49.5) 146(30.7)
improvement throughout NGHA
7) Patients‟ expectations about
quality plays a key role in setting
14(2.9) 27(5.7) 100(21.0) 240(50.4) 95(20.0)
priorities for quality
improvement at NGHA
8) NGHA does a good job
assessing current patient needs 16(3.4) 34(7.1) 110(23.1) 258(54.2) 58(12.2)
and expectations
9) NGHA does a good job
assessing future patient needs 19(4.0) 39(8.1) 124(26.1) 238(50.0) 56(11.8)
and expectations.
Domain 4: Human resource
utilization
A) Education and training :
1) Nurses at NGHA are given
21(4.3) 36(7.6) 65(13.7) 245(51.5) 109(22.9)
continues education and training
on methods that support quality
improvement.
2) Nurses at NGHA are given
the required education and
training (through nursing 23(4.8) 39(8.2) 61(12.8) 247(51.9) 106(22.3)
education programs) to improve
job skills and performance.
B) Rewards and recognition:
1) Nurses at NGHA are
rewarded and recognized (e.g. 61(12.8) 110(23.1) 147(30.9) 128(26.9) 30(6.3)
financially and/or otherwise) for
improving quality.
2) Inter-departmental
cooperation to improve the
24(5.0) 37(7.8) 123(25.8) 246(51.7) 46(9.7)
quality of services is supported
and encouraged at NGHA
3) NGHA has an effective
system for nurses to make
suggestions to management on 38(8) 80(16.8) 140(29.4) 187(39.3) 31(6.5)
how to improve quality.
Domain 5: Quality
Management
1) NGHA views Quality as a
9(1.9) 10(2.1) 90(18.9) 290(60.9) 77(16.2)
continuing search for ways to
improve.
2) NGHA has effective policies
to support improving the quality
of care and services (for 12(2.6) 4 (0.8) 57(12.0) 289(60.7) 114(23.9)
example: five right principle in
drug administration).
3) NGHA tries to introduce
quality into new services as they 10(2.1) 10(2.1) 9(18.9) 303(63.7) 63 (13.2)
are being developed.
4) The services that NGHA
provides are thoroughly tested
14(2.9) 43 (9.1) 152(31.9) 218(45.8) 49(10.3)
for quality before they are
implemented.
5) NGHA regularly checks
equipment and supplies to make
sure they meet quality 18(3.7) 28(5.9) 88(18.5) 257(54.0) 85(17.9)
requirements.

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6) NGHA encourages nurses to

keep records of quality problems 7(1.4) 16(3.4) 59(12.4) 298(62.6) 96(20.2)
through documentation.
Domain 6: Usage of Data
1) Nurses keep records of
patients‟ complaints to set action 13(2.8) 56(11.8) 92(19.3) 251(52.7) 64(13.4)
plans at NGHA.
2) Patient complaints are
analyzed to prevent future 16(3.4) 34(7.1) 102(21.4) 251(52.7) 73(15.4)
reoccurrence.
3) Data on patient satisfaction
are widely communicated to 34(7.1) 61(12.8) 124(26.1) 205(43.1) 52(10.9)
hospital staff at NGHA.
4) NGHA uses data from
15 (3.1) 26 (5.5) 141(29.6) 238(50.0) 56(11.8)
patients to improve services.
5) NGHA uses data on patient
expectations and/or satisfaction 19 (4.0) 33(6.9) 156(32.8) 228(47.9) 40(8.4)
when designing new service.

The majority of nurses reported that quality improvement
goals are known (82.5%), and that each department at
NGHA maintains specific goals to improve the quality
(80.9%). However, only two-thirds of nurses agreed
NGHA does a good job assessing current (66.4%) and
future (61.8%) patients‟ needs and expectations. The
majority of nurses agreed that nurses at the NGHA are
given education and training that support quality
improvement (74.4%) and improve job skills and
performance (74.2%). Yet, only one-third (33.2%) of
nurses reported that nurses at NGHA are rewarded and
recognized for improving quality, and 45.8% agreed on
existence of a system for nurses to make suggestions to
management on how to improve quality.
The majority of nurses agreed that NGHA has effective
policies to support improving quality of patient care
(84.6%) and encourages nurses to keep records of quality
problems through documentation (82.8%), yet only 56.1%
agreed that services provided by NGHA are thoroughly
tested for quality before implementation. With regard to
records on patients‟ complaints, about two-thirds of nurses
agreed that they are kept by nurses to set action plans
(66.1%), and are analyzed to prevent future re-occurrence
(68%). Regarding data on patients‟ satisfaction, about one-
half of nurses reported these data are communicated to
hospital staff at NGHA (54%) and are used when
designing new service (56.3%). Figure 2. shows a
significant direct association between levels of nurses‟
perception to accreditation impact and the PMS of
perception to quality of health care. As level of perception
to accreditation goes to positive, the PMS of QHC
significantly rises. This was evident for staff involvement
domain (F=136.38, p<0.001), benefits of accreditation
domain (F=225.16, p<0.001), and overall perception to
accreditation impact (F=263.86, p<0.001).

% mean
meanscore
score
of
Quality ofof
Quality
of Health
Health Care
90
9
Care
0
80
8 76.5 76.5
74.3 74.3 74.5 74.5
1 1
0
70
7 7 7 1 1
58.7
58.7 59.8 59.8 61.0
61.0
0
60
6 6 6
2 2 4 4 Positive
Negativ
0
50
5 42.6 42.6 eNeutral
Neutra
0
40 2 2
4 35.7 36.4
36.4
8 99 lPositiv
Negative
0
30
3 e
0
20
2
0
10
1
00
Staff
Staf
Involvement Benefitsof
Benefits Perception
Perception of
Involvemen
f accreditation
accreditatio accreditation
accreditatio
in taccreditation :
in of of
accreditation
Figure 2:Association
Figure 2: Nursing perception n
towards
between Nursing n and perceived quality of health care among
perception towards Accreditation
Accreditation nurses at King Abdulaziz Medical City, Riyadh, Saudi Arabia.

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 International Journal of Medicine and Medical Sciences, ISSN:2051-5731, Vol.47, Issue.1 1457
`

Table 5 shows that after adjustment for all nurses‟
personal characteristics, PMS of perception to
accreditation impact was a significant predictor of PMS of
perception to QHC (p<0.001). Aside from perception to
accreditation impact, nurses‟ perception to QHC was also
predicted with
level of education, years of experience and position.
Higher PMS of perception was more likely to be reported
by less educated (p<0.001), less experienced (pp=0.047)
nurses and those with direct patient care (p=0.041).

Table 5. Predictors of nurses‟ perceived quality of health care at King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Perceived Quality of health care (Percent mean score)

Predictors of Quality Leadership, Strategic Human Quality Usage Overall
commitment Quality resources Management of Quality of
QHC
support Planning utilization data health care

B t B t B t B t B t B t B t
Age -0.02 -0.191 -0.02 -0.191 0.12 1.465 0.08 0.726 0.12 1.456 0.01 0.107 0.05 0.787
(years)

Experience 0.03 0.277 -0.90 -0.945 -0.11 -1.414 -0.22 -2.004* -0.14 -1.823 -0.27 -2.698* -0.13 -1.992*
(years)

Gender -0.46 -0.224 1.50 0.748 2.53 1.53 0.01 0.003 0.57 0.348 -0.66 -0.307 0.89 0.633
Male=0
Female=1
Nationality 2.29 0.780 -1.09 -0.378 -2.36 -0.985 -1.88 -0.564 1.92 0.804 -7.14 -2.300* -1.47 -0.720
Non Saudi=0
Saudi=1
Education 4.17 2.002* 3.10 1.512 5.58 3.29* 6.09 2.575* 5.27 3.116* 8.17 3.717* 5.26 3.635*
categories
MSN/PHD=0
Tech/BSN=1
Position -3.37 -1.962 -3.18 -1.881 0.35 0.247 -3.93 -2.016* -2.68 -1.926 -3.77 -2.080* -2.44 -2.048*
Direct care=0
Managerial= 1
Accreditation 0.66 19.318* 0.82 24.13* 0.77 27.372* 0.78 20.065* 0.70 24.936* 0.79 21.829* 0.76 31.835*
(% mean score)

Constant 16.57 3.597* 6.35 1.398 5.31 1.42 0.46 0.088 13.67 3.653* 5.25 1.080 7.45 2.325*

B---- beta coefficient, t--- student t-test, *--- statistically significant.

Note---- Each predictor was adjusted for all other predictors in the table.
4. DISCUSSION
Accreditation processes are designed to ensure both
compliance and improvement by stimulating positive and
longitudinal change in organizational and clinical
practices, and its goal is to contribute to the production of
high quality and safe care for the benefits of consumers
[6]. NGHA assures that its facilities meet the needs of its
patients by focusing on patient safety, improved infection
control, and safe medical environments [9]. One of the
essential and vital components of JCI accreditation at
NGHA was the continuous efforts paid by nurses. Health
care quality is influenced by nursing and is often referred
to as “nurse-sensitive” care according to the National
Quality Forum [12]. This survey aimed to assess nurses‟
perception towards JCI accreditation and its impact on the
quality of care provided. The results showed percentage
mean score of 71.13±17.85 to nurses‟ perception to
hospital accreditation impact (neutral perception). This
PMS was 69.97+18.43 & 71.95+20.09, for staff
involvement and benefits of accreditation domains
respectively. Generally speaking, the results revealed that
nurses perceived an average improvement in quality as a
result of accreditation. This was in agreement with a study
in Lebanon, on hospitals that successfully passed both
national and international accreditation surveys [8], to
assess the perceived impact of accreditation on quality of
care from the health care professionals‟ point of view,
specifically nurses.
Studies showed that, in an increasingly evidence-based
world, scarce data were available on the impact of such
accreditation programs on the health systems and
customers‟ perception [13-15]. We surveyed nurses in an
effort to assess their perception of improvement in quality
of care as a result of hospital accreditation, including
contributing factors. The overall percentage mean score of
nursing perception towards hospital quality of health care
in this study was 66.87+16.71, reflecting an average level
of QHC. There was variability in the level of perception in
different domains, with the highest level for Quality

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`
management (70.76+16.64), Strategic Quality planning
(70.23+17.72), while Human resource utilization domain
was the least (61.15+20.86). The effect of accreditation on
patients‟ and providers‟ satisfaction in non-governmental
health units of Egypt was studied [7], where 30 accredited
non-governmental health units were compared with 30
unaccredited units using interview questionnaires
measuring satisfaction on Likert scales . It concluded that
accredited health centers showed higher patient
satisfaction compared to non-accredited health units.
Although there are studies suggesting that accreditation
promotes service change, [16-19] organizational change,
[10, 20] and professional development, [21-23] it is
equivocal whether quality of care or patient outcomes
show improvement which can be attributed to
accreditation [24-28]. In the present study, there was a
significant association between accreditation perception
and the overall perceived quality of health care and all its
domains, among nurses. Quality results increased by 0.67
for every unit increase in accreditation, with a variable
degree of change in different domains of quality, ranging
from 0.66 for quality domain to 0.82 for leadership
domain. In a study of the impact of accreditation on the
quality of hospital care in South Africa, the researchers
noticed a significant improvement in nurses‟ perception of
quality, especially clinical performance quality, but not for
teamwork and cooperation and not for participation in
decisions [27]. Duckett [29] noted that areas that showed
the least change with hospital accreditation were those
associated with medical staff. This was in agreement with
the findings of the present study, where improvements
were reported by 74.4% of nurses for services provided by
administration, as compared to only 50.7% who reported
improvement by clinical support of departments. This may
reflect that the way senior hospital management managed
the accreditation process may have had a direct effect on
improving quality results. Greenfield and Braithwaite [30]
confirmed this inconsistent relation between accreditation
and professional attitude.
Evidence shows that involvement of staff is crucial when
implementing changes or new initiatives in an
organization particularly when it comes to reducing
resistance to change [31]. In the present study, the
majority of nurses reported that important changes were
implemented during the preparation for the last survey
(68.9%) and reported that they participated in its
implementation at the NGHA (73.8%), and in their own
sections (73.7%). Staff involvement at all stages including
recognition can be beneficial to achieving the ultimate
goals of organization [32]. However, only 45.8% agreed
on existence of a system for nurses to make suggestions to
management on how to improve quality at NGHA.
Overall, staff involvement in accreditation was
significantly associated with better quality results as
perceived by nurses in the present study.
It has been confirmed that an adequate health workforce is
necessary for the delivery of essential health services and
improvement in health outcomes [33]. In many developing
countries such as in Rwanda, persistent lack of basic
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1458
equipment and supplies at facilities is one of the main
problems that are often overlooked [34]. However, this is
not the situation in Saudi Arabia, especially in KAMC
where allocation of available resources may need to look
at. In the present survey, although the majority of nurses
agreed that senior executives have articulated a clear
vision for the improvement of quality of care and services
at NGHA, yet only 55.4% agreed those seniors allocate
available resources to improve this quality. Evidence
shows that rewards and recognition influence staff
satisfaction, performance [35] and retention [36]. In the
present study, only one-third (33.2%) of nurses reported
that nurses at NGHA are rewarded and recognized for
improving quality.
Usage of data in accreditation process can help hospitals
track improvement activities, measure performance and
provide evidence for compliance to accreditation standards
[8]. With regard to records on patients‟ complaints, about
two-thirds of nurses – in the present study - agreed that
these records are kept by nurses to set action plans, and are
analyzed to prevent future re-occurrence. Regarding data
on patients‟ satisfaction, about one-half of nurses reported
these data are communicated to hospital staff at NGHA
and are used when designing new service. Accreditation
perception was significantly associated with the use of
data as a domain of quality of care, in the present study.
A study of Personal characteristics and association with
job satisfaction among nurses in Lebanon indicated the
importance of personal characteristics on nurses‟
satisfaction and retention [37]. The personal characteristics
examined in our study included age, gender, education
level, years of work experience and position. Higher
education was significantly associated with negative
perception to accreditation impact, even after adjustment
for other personal characteristics. Higher education was
also associated with negative perception to quality of care.
This was in agreement with Yamashati [38] who found
that more educated, the younger, and unmarried nurses
were less satisfied with their jobs than others. Nurses with
higher educational levels changed their jobs more
frequently; because the organizations they worked for
were unable or unwilling to meet their demands [38-40].
Age was also a significant predictor of nurses‟ perception
to accreditation, with elder nurses showing more positive
perception than younger ones did.
It has been reported by Tovey and Adams [41] that the
nature of nurses‟ job satisfaction is shaped by their
position within the organization. They stated that nurses of
lower clinical grades are concerned with managerial
constraints, whereas ward leaders experience
dissatisfaction as a result of strain and role conflict. This
was in agreement with the findings of the present study,
where nurses with direct patient care showed more
positive perception to quality of care than nurses with
managerial work. Moreover, nurses with longer
experience were less positive to quality of health care.
They may have felt more educated and more
knowledgeable, yet treated and compensated at almost the
same level as less experienced nurses.
 International Journal of Medicine and Medical Sciences, ISSN:2051-5731, Vol.47, Issue.1
`
Nursing community in Saudi Arabia is highly dependent
on expatriate manpower. Nurses from all over the world
have been migrating to this country since decades due to
the sever shortage in nursing and the overexpansion of the
population. Foreign nurses who participated in this study
originated mainly from far east Asia and neighboring
Arabian countries constituting 95% of all nurses in our
study. Saudi nurses were less positive towards both
accreditation impact and quality of health care. However,
after adjustment for other personal characteristics, they
were not different from non-Saudi nurses.
The present study had a limitation of unavailable pre-
intervention measures (pre-accreditation) and it is
recommended that future researches with controlled pre-
and post-design be carried out to evaluate the effect of
accreditation on the health services. This study was
conducted in one tertiary care setting and is not
representative of all health care delivery settings in the
Kingdom of Saudi Arabia, especially that KAMC is a
large hospital that is more likely to value and benefit from
accreditation, whereas smaller ones may be burdened by
costs of surveys and compliance in comparison with their
overall budgets [32]. Moreover, accreditation might have
been less threatening to large hospitals for political
reasons. A larger study involving more participant
organizations would have enabled more detailed analyses
examining the association between specific components of
accreditation and quality of health care.
5. CONCLUSION
This study has important implications for nurses,
especially in managerial positions. It addresses the impact
of perception to accreditation on other hospital duties
while preparing for accreditation such as the continuity
and quality of patient care during the preparation process.
Accreditation results predict quality of health care, and a
positive trend between accreditation and quality of health
care is noted. Strategies are required to reinforce the way
accreditation might lead to improved quality of care,
strengthen leadership, culture and climate, and how these
factors in turn might mediate accreditation performance.
ACKNOWLEDGMENT
The authors of this study extend their sincere gratitude to
King Abdullah International Medical Research Center.
Authors would like to thank Dr. Fadi El-Jardali for his
support. Special thanks to the nurses of Ward 12 and 13 at
National Guard Health Affairs as well as to Ms. Amal Al-
Oraini for their contributions in the pilot phase of this
study. Efforts of Ms. Abeer Al-Anazi concerning the data
base and registrar are well appreciated.
REFERENCES
[1]. Joint Commission International, 2011. Common
Questions and Answers Regarding JCI
Accreditation, Clinical Laboratories, and These
Standards. [Online]. Available at:
<https://www.google.com.sa/url?sa=t&rct=j&q=&e
src=s&source=web&cd=2&ved=0CDkQFjAB&url
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1459
=http%3A%2F%2Fwww.jointcommissioninternatio
nal.org%2Fcommon%2Fpdfs%2Fjcia%2FQuestion
sandAnswersCL.pdf&ei=MWdSUoeaIoiz0QXA_IF
I&usg=AFQjCNHso-
BfBgcVqozP5sTN3mwADpNtsA > [Accessed 7
October 2013]
[2]. Joint Commision Internatiol, 2011. About Joint
Commision Resources . [Online]. Avaliable at:<
http://www.jointcommissioninternational.org/about-
jci/>. [Accessed 7 October 2013]
[3]. The Joint Commision, 2011. History Of Joint
Commsion. [Online]. Avaliable at:<
http://www.jointcommission.org/assets/1/6/Joint_C
ommission_History.pdf> [Accessed 7 October
2013]
[4]. Helen Ziegler and Associates, 2011. What is JCI
Accreditation? [Online].Avaliable
at:<http://www.hziegler.com/locations/middle
east/articles/jci-accreditation.html> [Accessed 7
October 2013]
[5]. National Guard Health Affairs, 2010.
Accomplishments. [Online]. Avaliable
at:<http://www.ngha.med.sa/English/AboutNGHA/
Pages/Accreditation.aspx> [Accessed 7 October
2013]
[6]. Braithwaite, J. et al. (2010). Health service
accreditation as a predictor of clinical and
organizational performance: a blinded, random,
stratified study. BMJ Quality & Safety. P.14-21
[7]. Tehewy, M., Salem, B., Habil, I. & El Okda, S.
(2009). Evaluation of accreditation program in non-
governmental organizations‟ health units in Egypt:
short-term outcomes. International Journal for
Quality in Health Care. P.183-189.
[8]. El-Jardali et al. (2008). The impact of hospital
accreditation on quality of care: perception of
Lebanese nurses. International Journal for Quality
in Health Care. P. 363-371.
[9]. National Guard Health Affairs, 2010. JCI Re-
accreditation. [Online]. Available
at:<http://www.ngha.med.sa/English/MediaCenter/
News/Pages/2010-1-13_01.aspx> [Accessed
7 October 2013]
[10]. Pomey MP, Contandriopoulos AP, Francois P et al.
Accreditation: a tool for organizational change in
hospitals. Int J Health Care Qual Assur 2004;
17:113–24.
[11]. Shortell SM, O‟Brien JL, Carman JM et al.
Assessing the impact of continuous quality
improvement/total quality management: concept
versus implementation. Health Serv Res 1995;
30:377–401.
[12]. Elkins, G. et al. (2010). Perceived stress among
nursing and administration staff related to
 International Journal of Medicine and Medical Sciences, ISSN:2051-5731, Vol.47, Issue.1
`
accreditation. Clinical Nursing Research. P.367-
385.
[13]. Viswanathan HN, Salmon JW. Accrediting
organizations and quality improvement. Am J
Manag Care 2000; 6:1117–30?
[14]. Walsh K (Ed). Evaluating Clinical Audit: Past
Lessons, Future Directions. London: Royal Society
of Medicine, 1995.
[15]. Shaw C. External assessment of health care. BMJ
2001; 322:851–4.
[16]. Scrivens E, Klein R, and Steiner A. Accreditation:
what can we learn from the Anglophone model?
Health Policy 1995; 34:193e204.
[17]. Duckett S. Changing hospitals: the role of hospital
accreditation. Soc Sci Med 1983;17:1573e9.
[18]. Juul AB, Gluud C, Wetterslev J, et al. The effects of
a randomized multi-centre trial and international
accreditation on availability and quality of clinical
guidelines. Int J Health Care Qual Assur 2005;
18:321e8.
[19]. Sun˜ol R, Vallejo P, Thompson A, et al. Impact of
quality strategies on hospital outputs. Qual Safe
Health Care 2009; 18(Suppl 1):i62e8.
[20]. Longo D, Hewett J, Ge B, et al. Hospital patient
safety: characteristics of best performing hospitals.
J Health Manage 2007; 52:188e204.
[21]. Dickison P, Hostler D, Platt TE, et al. Program
accreditation effect on paramedic credentialing
examination success rate. Prehosp Emerg Care
2006; 10:224e8.
[22]. McCleish JM. Relationships between accreditation
affiliation, definitions, and tools used to assess
critical thinking as a learning outcome in schools of
nursing [PhD]. Iowa State University, 2002.
[23]. Tracey J, Arroll B, Richmond D. Changes in CME
uptake caused by reaccreditations. N Z Med J
1998;111:118e20.
[24]. Griffith JR, Knutzen SR, Alexander JA. Structural
versus outcomes measures in hospitals: a
comparison of Joint Commission and Medicare
outcomes scores in hospitals. Qual Manag Health
Care 2002; 10:29e38.
[25]. Miller MR, Pronovost P, Donithan M, et al.
Relationship between performance measurement
and accreditation: implications for quality of care
and patient safety. Am J Med Qual 2005;
20:239e52.
[26]. Dean Beaulieu N, Epstein AM. National Committee
on Quality Assurance health plan accreditation:
predictors, correlates of performance, and market
impact. Med Care 2002; 40:325e37.
© RECENT SCIENCE PUBLICATIONS ARCHIVES| March 2014|$25.00 | 27703335 |
*This article is authorized for use only by Recent Science Journal Authors, Subscribers and Partnering Institutions*`
View publication stats
1460
[27]. Salmon J, Heavens J, Lombard C, et al. The Impact
of Accreditation on the Quality of Hospital Care:
KwaZulu-Natal Province Republic of South Africa.
Operations Research Results 2(17): Published for
US Agency for International Development
(USAID) by Quality Assurance Project, Bethesda
(MD): University Research Co., LLC., 2003.
[28]. Grasso B, Rothschild J, Jordan C, et al. What is the
measure of a safe hospital? Medication errors
missed by risk management, clinical staff and
surveyors. J Psychiatr Pract 2005; 11:268e73.
[29]. Duckett SJ. Changing hospitals: the role of hospital
accreditation. Soc Sci Med 1983; 17:1573–9.
[30]. Greenfield D, Braithwaite J. Health sector
accreditation research: a systematic review. Int J
Qual Health Care 2008; 20: 172–83.
[31]. Seren S, Baykal U, Relationships between change
and organizational culture in hospitals. J Nurs
Scholarsh 2007; 39:181–7.
[32]. Montagu D, Accreditation and other external
quality assessment systems for healthcare: Review
of experience and lessons learned. London:
Department for International Development Health
Systems Resource Centre, 2003.
http://www.dfidhealthrc.org/publications/health_ser
vice_delivery/Accreditation.pdf
[33]. Chan, C. P., W. C. Mak, et al. (2013). "Evidence-
based point-of-care diagnostics: current status and
emerging technologies." Annu Rev Anal Chem
(Palo Alto Calif) 6: 191-211.
[34]. Binagwaho, A., P. Kyamanywa, et al. (2013). The
human resources for health program in Rwanda-
new partnership. N Engl J Med 369(21): 2054-
2059.
[35]. Chandra, A. (2003). "Why do nurses leave and what
can health oganizations do to retain them?" Hosp
Top 81(3): 33-36.
[36]. Wagner, S. E. (2006). "Staff retention: from
"satisfied" to "engaged"." Nurs Manage 37(3): 24-
29; quiz 30.
[37]. Yaktin, U. S., N. B. Azoury, et al. (2003). "Personal
characteristics and job satisfaction among nurses in
Lebanon." J Nurs Adm 33(7-8): 384-390.
[38]. Yamashati M. Job satisfaction in Japanese nurses. J
Adv Nurs. 1995; 22: 158–164. [
[39]. Cavanagh SJ. Job satisfaction of nursing staff
working in hospitals. J Adv Nurs.1992;17:704–711.
[40]. Blegen M. Nurses‟ job satisfaction: a meta-analysis
of related variables. Nurs Res. 1993; 42( 1):36–41.
[41]. Tovey EJ, Adams AE. The changing nature of
nurses‟ job satisfaction: an exploration of sources of
satisfaction in the 1990s. J Adv Nurs. 1999; 30( 1):
150–158.