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International Journal for Quality in Health Care 2008; Volume 20, Number 5: pp.

363 371 Advance Access Publication: 1 July 2008

10.1093/intqhc/mzn023

The impact of hospital accreditation on quality of care: perception of Lebanese nurses


FADI EL-JARDALI1, DIANA JAMAL1, HANI DIMASSI2, WALID AMMAR3 AND VICTORIA TCHAGHCHAGHIAN1
1 3

Health Management and Policy Department, American University of Beirut, 2School of Pharmacy, Lebanese American University, and Ministry of Public Health in Lebanon

Abstract
Background. In developing countries, accreditation is increasingly being used as a tool for government regulation to guarantee quality of care. Although Lebanon is the rst country in the East Mediterranean Region to develop and implement accreditation standards, little is known yet on its impact on quality of care. Objective. To assess the perceived impact of accreditation on quality of care through the lens of health care professionals, specically nurses. This paper also investigates the perceived contributing factors that can explain change in quality of care. Methods. A cross-sectional survey design where all hospitals that successfully passed both national accreditation surveys (I and II) were included. A total of 1048 registered nurses from 59 hospitals were sampled. The survey tool, assessing quality of care and contributing factors, includes nine scales and subscales rated on ve-point Likert scale. Results. The high score for the variable Quality Results indicates that nurses perceived an improvement in quality during and after the accreditation process. Predictors of better Quality Results were Leadership, Commitment and Support, Use of Data, Quality Management, Staff Involvement and hospital size. The variable Quality Management, as measured by the scale Quality Management, had the greatest impact in medium-sized hospitals while the subscale measuring Staff Involvement had the greatest impact in small-sized hospitals. Conclusion. According to Lebanese nurses, hospital accreditation is a good tool for improving quality of care. In order to ensure that accreditation brings effective quality improvement practices, there is a need to assess quality based on patient outcome indicators. Keywords: quality improvement, accreditation, hospitals, quality of care, nursing

INTRODUCTION
Accreditation is a process whereby an organization is assessed on a set of pre-determined standards [1, 2]. It intends to promote quality improvement through diverse approaches; they are either mandated by the government, voluntary or initiated by independent agencies [2]. Although many health-care organizations in developing countries are undergoing or considering accreditation, there is little research on its impact [3] and consequently no conclusive evidence that it improves quality of care [4 6]. Quality of care is now prominent on health policy agendas of governments of several countries in the East Mediterranean Region. A study conducted in 2000 by the World Health Organization revealed that there were no accreditation programs in the Eastern Mediterranean [7]. Since then, several countries

in this region have been developing and implementing accreditation programs [8]. Among those countries, Lebanon was the rst to develop and implement a national accreditation program. Since its implementation in 2002, little is known on its impact on quality of care in Lebanese hospitals [8]. Although there are many different denitions for quality [9], in this study, quality refers to two simple domains, the technical and interpersonal [10]. This focus does not include continuity of care.

Context
The Ministry of Public Health implemented accreditation through two national surveys [11]. The First National Survey (Survey I) was implemented between September 2001 and July 2002 and 128 hospitals were surveyed. Small-sized hospitals

Address reprint requests to: Fadi El-Jardali, Health Management and Policy Department, American University of Beirut, Lebanon. E-mail: fe08@edu.lb
International Journal for Quality in Health Care vol. 20 no. 5 # The Author 2008. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

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(,100 beds) accounting for the majority of hospital beds in Lebanon were, on average, operating below standards. Medium-sized hospitals (101200 beds) got a somewhat better average score than large-sized hospitals (.200 beds) [11, 12]. The Second Survey (Survey II) was launched in 2004. In this survey, accreditation standards and scoring mechanisms changed slightly. Among the 142 surveyed hospitals, only 85 met the requirements. Large-sized hospitals had higher ratings than medium-sized hospitals while small-sized hospitals had the lowest rating. The remaining 57 hospitals failed to meet accreditation requirements [11]. Study objectives The objective is to assess the perceived impact of accreditation on quality of care through the lens of health-care professionals, specically nurses. This study also investigates the perceived contributing factors that can explain changes in quality of care. Studies by Shortell et al. and Pomey et al. [13, 14] provided conceptual guidance to our study. In their article, Shortell et al. [13] argued that quality improvement implementation leads to greater perceived patient outcomes. Furthermore Shortell et al. [13] found that large-sized hospitals face some difcult challenges in terms of quality improvement implementation, underlining the importance of assessing hospital size. Pomey et al. [14] assessed organizational changes after accreditation in France and argued that accreditation can promote quality improvement implementation in hospitals thus leading to better outcomes.

[16] and are therefore most likely to feel the impact of accreditation on quality. The sample was limited to Registered Nurses, that is, nurses holding at least a Bachelors of Science in Nursing, Baccalaureate Technique, Technique Superior, or License Technique. Moreover, only nurses who have been working in the hospital for at least 4 years (i.e. had passed through both accreditation surveys I and II) were surveyed. On the basis of discussion with hospital and nurse managers and given that there is no ofcial estimate on the number of nurses practicing in Lebanese hospitals, we sampled at least 50% of practicing nurses at each hospital. After computing an average of the estimated number of nurses within each size category, the 38 small-sized hospitals were each asked to return 21 questionnaires, while the 16 medium-sized hospitals were requested to return 45 questionnaires each and the ve largesized hospitals were asked to return 90 questionnaires each. A total of 1968 questionnaires were sent, however, only 1485 questionnaires were collected (755% response rate). In some hospitals, nurses who had ,4 years experience mistakenly lled the questionnaire; they were excluded and 1048 nurses were included in our nal sample (see Fig. 1). Survey instrument Very few instruments are available in the literature to evaluate quality implementation and outcomes in health-care organizations, particularly in the context of accreditation. There is no such instrument that can be used worldwide for healthcare organizations. For our study, we used scales that were developed in previous studies. As shown in Table 1, all the scales used in this study are adapted from Shortell et al. [13] with the exception of one scale that was adapted from Pomey et al. [14]. The wording of few questions was modied to t the local culture with no change in content. Each of the 54 items used are described in Appendix I. Scales were translated to Arabic. The Arabic version was backtranslated to English and compared with the original version. Both language versions of the questionnaire were pilot tested on 15 nurses; each nurse completed both versions with a 1-week time interval. Cronbach Alpha exceeded 0.60 for all scales in both language versions (see Table 1). The nal survey tool consisted of nine scales and subscales that were rated on a ve-point Likert scale (ranging from one for strongly disagree to ve for strongly agree). A section on demographics (gender, age, educational qualications, occupational category and years of experience) was also included. The dependant variable was Quality Results, whereas the independent variables were Leadership, Commitment and Support; Strategic Quality Planning; Quality Management; Human Resource Utilization; Use of Data; and Accreditation. Before proceeding with the survey, ethical approval was obtained from the Institutional Review Board of the American University of Beirut. Data analysis Data were analyzed using SPSS 15.0 and analyses were carried out at the 0.05 signicance level. Data analysis steps are detailed below.

METHODS
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. This assessment took into consideration the size of hospitals since it may impact quality improvement implementation [13]. Study design This research study followed a cross-sectional survey design where all sixty-eight hospitals that successfully passed both surveys (I and II) were included. A total of fty-nine hospitals consented to participate. To compare hospitals with similar service and care characteristics, hospitals were stratied by size into three categories dened by the Lebanese Ministry of Health as follows: small- (100 beds), medium(101 200 beds) and large-sized (.200 beds). This stratication also allowed observing variations in quality results by hospital size. Fig. 1 details the selection process of hospitals. Selection of respondents The health professionals targeted for this study were nurses. Evidence shows that nurses are key factors in quality of care and are interested in providing good patient outcomes [15]. In fact, nurses spend up to 90% of their time caring for patients

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Figure 1 Sampling procedure and response rate. Descriptive analysis. To describe the characteristics of the respondents, univariate statistics were performed. Mean scores were computed for every scale and subscale based on the number of available items. Comparing hospitals of different size (ANOV ANOV was A). A performed to compare mean scores for each scale and subscale across small-, medium- and large-sized hospitals. The Bonferroni correction was used as a multi-comparison technique. Creation of factor scores. Principal component factor analysis was conducted with orthogonal rotation (varimax) to create factor scores. Eigen values exceeding 1.0 were considered.

Table 1 Breakdown of sources of each scale, number of items in each scale and subscale in addition to Cronbach Alpha from Pilot Sample and Total Sample Scale name Number of items Source
...........................

Pilot sample

...........................

Total sample

English Quality results Leadership, commitment and support Strategic quality planning Human resources utilization Education and training Rewards and recognition Quality management Use of data Accreditation Staff Involvement Benets of Accreditation N 5 9 7 6 3 3 6 7 14 5 9 [13] [13] [13] [13] [13] [13] [13] [13] [14] [14] [14] 0.79 0.64 0.71 0.80 0.69 0.82 0.86 0.75 0.89 0.84 0.92 15

Arabic 0.90 0.91 0.86 0.93 0.96 0.81 0.90 0.85 0.89 0.86 0.92

English 0.89 0.91 0.85 0.85 0.87 0.84 0.88 0.90 0.96 0.87 0.93 1048

Arabic 0.89 0.92 0.84 0.88 0.87 0.81 0.88 0.91 0.94 0.91 0.96

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One factor score was calculated for each of the scales with the exception of those on human resources utilization and accreditation, each of which yielded two factor scores. As mentioned before, the factor score representing Quality Results was considered the dependant variable. The remaining factor scores in addition to the variable representing hospital size were considered the explanatory/independent variables. Association between the dependant and independent variables. The dependant variable (factor score on quality results) was correlated against the independent variables represented by their factors scores using Pearson correlation coefcient. The correlation analysis was also stratied by hospital size to assess any effect of size on the correlation coefcients. The dependant variable was then regressed against all independent variables represented by their factors scores. Interactions between independent variables and hospital size were also investigated. When found signicant, the main effect and interaction terms were used to create simple effect terms. All analyses were corrected for nurses demographic characteristics and only statistically signicant variables were kept in the model.

Table 2 Descriptive Statistics on the study sample N Gender Female Male Age groups , 30 years 30 45 years 46 55 years . 56 years Degrees Bachelors of Science Technique Superior Baccalaureate Technique License Technique Masters Degree Midwife Occupational categories Nurse Head nurse Other Supervisor Midwife Number of nurses across hospital size Small (,100 beds) Medium (100 200 beds) Large (.201 beds) 877 156 340 614 70 14 344 264 229 104 85 10 600 365 42 22 8 374 333 341 % 84.9 15.1 32.8 59.2 6.7 1.4 33.2 25.5 22.1 10.0 8.2 1.0 57.9 35.2 4.1 2.1 0.8 35.7 31.8 32.5

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Results
Descriptive analysis As observed in Table 2, the majority of sampled nurses were females (84.9%), and most of them being between 30 and 45 years of age (59.2%). The vast majority of sampled nurses held a Bachelors of Science in Nursing, Technique Superior or Baccalaureate Degree with minimal representation from nurses holding License Technique, Masters in Science or Midwifery degrees. Most of the sampled nurses held staff nurse positions in their hospitals (57.9%). The respondents were equally distributed across small-, medium- and largesized hospitals. Comparing hospitals of different size. As observed in Table 3, the score on the scale that measures Quality Results was 4.09 (+0.72). This indicates that nurses perceived an improvement of Quality Results in hospitals as an outcome of accreditation. In terms of the Benets of Accreditation subscale, the mean score of 4.11 (+0.66) indicates that nurses perceived improved team work and productivity in hospitals as an outcome of accreditation. Rewards and Recognition had the lowest agreement score (mean 3.41) while the Use of Data subscale (mean 4.15) had the highest agreement score. The mean scores for all scales and subscales were signicantly different across hospital sizes, with the exception of the scale on Leadership, Commitment and Support. Signicant differences were observed specically between small- and large-sized hospitals in addition to medium- and large-sized hospitals, with no signicant differences between small- and medium-sized hospitals. The scales and subscales followed a general trend of having the lowest score in large-sized hospitals, slightly higher for small-sized hospitals and highest for medium-sized hospitals. The exceptions were the scale on Quality Results and the subscale on Benets of Accreditation

where the highest scores were observed for small-sized hospitals. Association between the dependant and independent variables. The dependant variable (quality results) was found to be positively correlated with all scales with the Pearson R ranging from 0.53 (benets of accreditation) to 0.73 (use of data). No major differences were observed when stratifying by hospital size. Table 4 presents the regression model where quality results was the dependant variable regressed against factor scores and hospital size. The model had an R 2 of 0.68 depicting a good t. The model indicated that the predictors of better quality results were leadership, commitment and support; use of data; quality management; staff involvement and hospital size. Quality results increased by 0.18 and 0.39 for every unit increase in leadership, commitment and support and use of data, respectively. This may indicate that the way senior hospital management managed the accreditation process and the capability of the hospital to use data to improve quality may have had a direct effect on improving quality results. The situation was slightly more complex for the other two scales due to the presence of interaction terms. The scale on quality management was observed to have the greatest impact in medium-sized hospitals where for every unit increase in quality management, perceived improvement in Quality Results increased by 0.40 (P , 0.001). This may indicate that medium-sized hospitals were more responsive

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Table 3 Distribution of the score of the study variables Overall Mean Condence (SD) Interval (95%) Quality results Leadership, commitment and support Strategic quality planninga,b Education and traininga,b Rewards and recognitiona,b Quality managementa,b Use of dataa,b Staff involvement in accreditationa,b Benets of accreditation
a b

Mean (SD) for small hospitals 4.24 (0.60) 4.05 (0.72)

Mean (SD) for medium hospitals 4.20 (0.71) 4.07 (0.58)

Mean (SD) for large hospitals 3.82 (0.79) 3.96 (0.68)

P-value ,0.001 0.10 ,0.001 ,0.001 ,0.001 ,0.001 ,0.001 ,0.001 0.04

............................................................................................................................................................................. a,b

4.09 (0.72) 4.02 (0.67)

4.05 4.17 4.01 4.13

4.08 (0.63) 4.12 (0.79) 3.41 (1.04) 4.12 (0.66) 4.15 (0.67) 4.11 (0.70) 4.11 (0.66)

40.5 4.16 4.07 4.21 3.46 3.64 4.09 4.21 4.08 4.20 4.05 4.19 4.03 4.15

4.14 (0.62) 4.15 (0.78) 3.50 (1.02) 4.16 (0.64) 4.26 (0.64) 4.20 (0.69) 4.16 (0.63)

4.18 (0.58) 4.26 (0.75) 3.53 (1.00) 4.22 (0.62) 4.27 (0.60) 4.13 (0.60) 4.15 (0.61)

3.92 (0.67) 3.95 (0.82) 3.20 (1.07) 3.99 (0.70) 3.93 (0.71) 3.97 (0.77) 4.03 (0.72)

Signicant difference between medium and large hospitals. Signicant difference between small and large hospitals. SD, standard deviation.

Table 4 Regression model testing for the predictors of quality results Betaa (standard error) Factor score: leadership, 0.18 (0.04) commitment and support Factor score: use of data 0.39 (0.04) Factor score: quality management In small hospitals 20.09 (0.07) In medium hospitals 0.40 (0.14) In large hospitals 0.05 (0.14) Factor score: staff involvement in accreditation In small hospitals 0.26 (0.06) In medium hospitals 0.06 (0.14) In large hospitals 0.22 (0.13) Hospital size (medium vs. small) 20.15 (0.06) Hospital size (large vs. small) 20.27 (0.06) 0.68 Adjusted R 2 N 503 P-value ,0.001 ,0.001 0.17 0.004 0.71 ,0.001 0.68 0.08 0.02 ,0.001

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greatest impact in small-sized hospitals where the increase in quality results per unit of the independent variable was 0.26 (P , 0.001). For large- and medium-sized hospitals, staff involvement failed to show signicance with quality results. This observation may indicate that hospital staff was more involved in accreditation in small-sized hospitals, and such involvement helped hospitals improve its quality results.

Discussion
In this study, nurses perceived improvement in quality as a result of accreditation. Accreditation seems to have improved perceived quality of care in sampled hospitals, with signicant differences across hospital size. With the exception of the subscale on Leadership, Commitment and Support, better results were observed in small- and medium-sized hospitals for all scales and subscales. This nding is particularly important since evidence shows that larger organizations are more likely to value and benet from accreditation whereas smaller organizations may be burdened by costs of surveys and compliance in comparison with their overall budgets [2]. Evidence shows that smaller organizations often have a more homogeneous culture and its staff probably shares the same values [17]. Large-sized hospitals tend to be more hierarchically and bureaucratically organized which makes implementation of quality work more challenging [13]. In fact, increasing organizational size is also inversely related to an employees attachment to an organization and hence his/her performance [17]. Although the relationship between hospital size and quality results as an outcome of accreditation has not been explored much, we believe that our ndings merit further research. In the Lebanese context, larger hospitals have been

a Beta stands for the average change in Quality Results score per unit increase in independent variable scores.

to quality needs such as creating policies and procedures, designating new services or checking and maintenance of equipment which may have contributed to improving Quality Results. For large- and small-sized hospitals, the impact of the scale measuring quality management failed to show statistical signicance. Staff Involvement in accreditation had the

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implementing quality improvement initiatives (such as International Standards Organization, etc.) even before implementing the national accreditation program. In fact, they have been delivering services of a certain standard of quality for a long-time. Thus, they may have had narrower room for improvement. Another explanation related to our nding on hospital size has to do with the accreditation standards themselves. It might be that accreditation standards were made more tailored to t small- and medium-sized hospitals since the priority for the Ministry of Public Health is to improve service delivery in poor performing hospitals (mostly small- and medium-sized hospitals). This might explain why results in large-sized hospitals were not better than small- and medium-sized hospitals. In other words, the differential improvement in quality as a result of accreditation was small in large-sized hospitals. As for the majority of small- and medium-sized hospitals, the concept of quality improvement and accreditation was new. That is probably why improvements that have been brought to those hospitals as a result of accreditation were more signicant. It is important to note the Ministry of Public Health had linked accreditation to contracting with private hospitals. In other words, hospitals that fail accreditation cannot contract with the ministry and provide services to its patients. Although a signicant amount of revenues for most of the small- and medium-sized hospitals in Lebanon come from delivering services to ministry patients, it might be possible that those hospitals considered accreditation as a serious threat for losing their contracts. As a result, it might be possible that they had incentives to effectively implement accreditation standards. In Lebanon, the main sources of revenue for large private hospitals are out-of-pocket patients and private third party payers. They depend less on public funds to survive. In addition, the Ministry of Public Health cannot afford not to contract with large hospitals. This is due to patients preference in addition to other political reasons. That is why accreditation might have been less threatening to large hospitals. Study results revealed that the variable on leadership, commitment and support was signicantly associated with quality results. The high scores observed in ANOV indicate that A senior management was highly committed to the accreditation in their hospitals. However, the level of senior management commitment was lowest for large hospitals and almost equal between small and medium hospitals. To explain this nding, research evidence shows that having continuous and direct lines of communication between top-level managers and their employees can facilitate organizational change, but this relationship diffuses slowly as hospital size increases [18]. Furthermore, evidence shows that the willingness of employees to undertake quality improvement activities is signicantly associated with hospitals culture in addition to the degree of teamwork and support [13]. The measure for staff Involvement was also signicantly associated with better quality results. Signicant differences were observed particularly between small- and medium-sized hospitals. 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 [18]. Since an organizations decision to reach accreditation requires high short-term investment which can yield long-term benets that are not always guaranteed [19], staff involvement at all stages including recognition can be benecial to achieving the ultimate goals of the organization [2]. To achieve this, the management and support given by the administration can play an important role [2]. In this context, it is worth mentioning that while rewards and recognition was not found to be a predictor of quality results in hospitals, this subscale had the lowest overall score. Evidence shows that rewards and recognition inuence staff satisfaction, performance [20] and retention [21]. The variable on use of data was found to be signicantly associated with improved quality at accredited hospitals. This demonstrates the importance of using data in driving quality improvement activities. While no literature was found to document the association between the use of data and accreditation, it is important to note that the use of data in the accreditation process can help hospitals track improvement activities, measure performance and provide evidence for compliance to accreditation standards. Three limitations for this study should be recognized. The rst lies in the fact that our results are based on the perception of nurses, with no further analysis of patient outcome data. Although patient outcomes could be a good indicator of quality improvement, hospitals in Lebanon do not have standardized outcome indicators. The second limitation was the differential response rate across hospitals of different sizes (46.9% in small hospitals, 46.3% in medium hospitals and 75.8% in large hospitals). The overall response rate in small- and medium-sized hospitals is lower as some hospitals provided us with fewer questionnaires than requested since they had a low number of nurses. Nurses working in small-sized hospitals may have different scope of practice than nurses working in larger hospitals indicating that we may have sampled a specic group of nurses. This may have impacted their perception of quality. To investigate this, we should have ideally compared the sampled nurses to nonrespondents, but access to this information posed ethical concerns. We therefore compared these nurses to respondents from large-sized hospitals because we had higher response there. Since they were not different in terms of age, degree or gender, we deduced that a response bias was unlikely to have occurred. In this context, it is important to note that the overall response rate (75.5%) was acceptable. Another limitation was selecting only hospitals that passed through both accreditation surveys. One might argue that results generated from hospitals that underwent two accreditation surveys may not be generalized to hospitals that undergo accreditation for the rst time. These hospitals might react to the survey in a different manner.

Conclusion
According to Lebanese nurses, hospital accreditation is a good tool for improving quality of care. Study ndings could inform policy makers and hospital managers in Lebanon

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who are currently working to further develop the accreditation program and its implementation. In order to make accreditation an effective regulatory instrument, there is a need to assess quality based on patient outcome indicators. This can be done by strengthening the current accreditation program to be more outcomes oriented. Study ndings will also provide valuable lessons for other countries in the region which are preparing or implementing accreditation.

14. 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. 15. Aiken L, Patrician PA. Measuring organizational traits of hospitals: the revised nursing work index. Nurs Res 2000;49: 146 53. 16. OBrien-Pallas L, Alksnis C, Wang S et al. Early retirement among RNs: estimating the size of the problem in Canada, Longwoods Rev 2003;1:2 9. 17. El-Jardali F. The impact of hospital rationalization and the interrelationships among organizational culture and nursing care processes on health related patient outcomes, Ph.D. Thesis. Carleton University, Canada, 2003. 18. Seren S, Baykal U, Relationships between change and organizational culture in hospitals. J Nurs Scholarsh 2007;39:181 7. 19. DAndrea G, Analyzing the value of accreditation: application of computer decision tools to a complex decision, Lippincotts Case Manag 2006;11:249 52. 20. Chandra A, Why do nurses leave and what can health organizations do to retain them. Hosp Top 2003;81:336. 21. Wagner SE. Staff retention: from satised to engaged. Nurs Manag 2006;37:25 30.

Funding
This study was funded by the American University of Beirut University Research Board.

References
1. Klazinga N. Re-engineering trust: the adoption and adaption of four models for external quality assurance of health care services in western European health care systems. Int J Qual Health Care 2000;12:183 9. 2. 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.ddhealthrc.org/publications/health_service_delivery/Accreditation.pdf 3. Buetow SA, Wellingham J. Accreditation of general practice: challenges and lessons. Qual Saf Health Care 2003;12:129 35. 4. Viswanathan HN, Salmon JW. Accrediting organizations and quality improvement. Am J Manag Care 2000;6:1117 30. 5. Salmon JW, Heavens J, Lombard C et al. Quality Assurance Project, The Impact of Accreditation on the Quality of Hospital Care: KwaZulu-Natal Province, Republic of South Africa, 2003, www. qaproject.org/pubs/PDFs/SAfrAccredScreen.pdf 6. Shaw CD, External assessment of health care. BMJ 2001;322: 851 4. 7. World Health Organization. Quality and Accreditation in Health Care Services: A Global Review. Geneva, Switzerland: World Health Organization, 2003. http://whqlibdoc.who.int/hq/ 2003/WHO_EIP_OSD_2003.1.pdf 8. El-Jardali F, Hospital accreditation policy in Lebanon: its potential for quality improvement. LMJ 2007;55:3945. 9. McGlynn EA, Six challenges in measuring the quality of health care. Health Aff 1997;16:7 21. 10. Donabedian A, The Denition of Quality and Approaches to Its Assessment, Health Administration Press: Ann Arbor, 1980. 11. Ammar W, Wakim R, Hajj I. Accreditation of hospitals in Lebanon: a challenging experience. East Mediterr Health J 2007;13:138 49. 12. Ammar W Health System and Reform in Lebanon. World Health , Organization Eastern Mediterranean Regional Ofce: Beirut, 2003. 13. Shortell SM, OBrien JL, Carman JM et al. Assessing the impact of continuous quality improvement/total quality management: concept versus implementation. Health Serv Res 1995;30:377401.

Appendix I. Questions used in data collection. Questions in all scales are rated on a ve-point Likert Scale (1, strongly disagree; 5, strongly agree)
Quality results (ve items)

(i) Over the past 4 years, the hospital has shown steady, measurable improvements in the quality of customer satisfaction. (ii) Over the past few years, the hospital has shown steady, measurable improvements in the quality of services provided by the administration (nance, human resources, etc.) (iii) Over the past few years, the hospital has shown steady, measurable improvements in the quality of care provided to patients (e.g. medical, surgical, obstetric and paediatric patients). (iv) Over the past few years, the hospital has shown steady, measurable improvements in the quality of services provided by clinical support departments such as laboratory, pharmacy, and radiology. (v) Over the past few years, the hospital has maintained a high quality health services despite nancial constraints.
Leadership, commitment and support (nine items)

(i) Senior hospital executives provide highly visible leadership in maintaining an environment that supports quality improvement.

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(ii) The top management is a primary driving force behind quality improvement efforts. (iii) Senior hospital executives allocate available hospital resources (e.g. nances, people, time, and equipment) to improving quality. (iv) Senior hospital executives consistently participate in activities to improve the quality of care and services. (v) Senior hospital executives have articulated a clear vision for improving the quality of care and services. (vi) Senior hospital executives have demonstrated an ability to manage the changes (e.g. organizational, technological) needed to improve the quality of care and services. (vii) Senior hospital executives have started to act on suggestions to improve the quality of care and services. (viii) Based on the accreditation results, senior hospital executives have a thorough understanding of how to improve the quality of care and services. (ix) Senior hospital executives generate condence that efforts to improve quality will succeed.
Strategic quality planning (seven items)

(b) Inter-departmental cooperation to improve the quality of services is supported and encouraged. (c) The hospital has an effective system for nurses to make suggestions to management on how to improve quality.
Quality management (six items)

(i) The hospital regularly checks equipment and supplies to make sure they meet quality requirements. (ii) The hospital has effective policies to support improving the quality of care and services (example: Five Rights Principle in Drug Administration). (iii) The hospital tries to design quality into new services as they are being developed. (iv) The services that the hospital provides are thoroughly tested for quality before they are implemented. (v) The hospital views quality assurance as a continuing search for ways to improve. (vi) The hospital encourages nurses to keep records of quality problems through documentation.
Use of data (seven items)

(i) Nurses are given adequate time to plan for and test quality improvements. (ii) Each department and work group within this hospital maintains specic goals to improve quality. (iii) The hospitals quality improvement goals are known throughout your unit. (iv) Nurses are involved in developing plans for improving quality. (v) Middle managers (e.g. Nurse heads, Director of Nursing or Clinical specialist) play a key role in setting priorities for quality improvement. (vi) Patients expectations about quality play a key role in setting priorities for quality improvement. (vii) Nurses play a key role in setting priorities for quality improvement through representation in the hospitals organizational chart.
Human resources utilization (six items)

(i) The hospital does a good job of assessing current patient needs and expectations. (ii) The hospital does a good job of assessing future patient needs and expectations. (iii) Nurses promptly resolve patient complaints. (iv) Patients complaints are studied to identify patterns and learn from them to prevent the same problems from recurring. (v) The hospital uses data from patients to improve services. (vi) Data on patient satisfaction are widely communicated to hospital staff. (vii) The hospital uses data on patient expectations and/ or satisfaction when designing new services.
Accreditation (14 items) Staff involvement (i) During the preparation for the last survey, important changes were implemented at the hospital. (ii) You participated in the implementation of these changes. (iii) You learned of the recommendations made to your hospital since the last survey (if its the case). (iv) These recommendations were an opportunity to implement important changes at the hospital. (v) You participated in the changes that resulted from accreditation recommendations. Benets of accreditation (i) Accreditation enables the improvement of patient care. (ii) Accreditation enables the motivation of staff and encourages team work and collaboration.

(i) Education and Training Subscale (a) Nurses are given education and training in how to identify and act on quality improvement opportunities based on recommendations from accreditation surveys (b) Nurses are given continuous education and training in methods that support quality improvement. (c) Nurses are given the needed education and training (through nursing education programs) to improve job skills and performance. (ii) Rewards and recognition subscale (a) Nurses are rewarded and recognized (e.g. nancially and/or otherwise) for improving quality.

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(iii) Accreditation enables the development of values shared by all professionals at the hospital. (iv) Accreditation enables the hospital to better use its internal resources (e.g. nances, people, time, and equipment). (v) Accreditation enables the hospital to better respond to the populations needs. (vi) Accreditation enables the hospital to better respond to its partners (other hospitals, diverse hospitals, private clinics, etc.) (vii) Accreditation contributes to the development of collaboration with partners in the health care system. (viii) Accreditation is a valuable tool for the hospital to implement changes. (ix) The hospitals participation in accreditation enables it to be more responsive when changes are to be implemented.

Demographic information
(i) Gender. (ii) Age (Below 30 years; Between 30 and 45 years; Between 46 and 55 years; Over 50 years). (iii) How long have you worked for or been associated with this hospital? (years and months). (iv) What is your highest Nursing educational credential? (Baccalaureate Technique; Technique Superior; Bachelors of Science; License Technique; Masters degree or equivalent; Specify if other degree). (v) What is your occupational category? (Head Nurse; Nurse, Supervisor, Specify if other).

Accepted for publication 2 June 2008

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