At the time of the study, the total number of staff at the hospital was 5695. A target sample size of 20% of the hospital staff was set which amounts to a total of 1139. A total of 630 respondents completed the survey which reflects a total response rate of 55.3%. As detailed in Table 1 below, the majority of respondents were females (67.6%), and most were aged between 30 and 45 (64.1%). Respondents had an average tenure of 10.98 years (SD=7.23) at the hospital and 8.98 years (SD=6.29) in their current position. Most respondents held a bachelor’s degree (45.2%) and 46.8% were nurses. A total of 83.8% of respondents participated in at least two accreditation cycles. The average response for respondent involvement in the accreditation process was 5.51 (SD=1.48). However, respondents reported an average score of 7.63 (SD=2.01) in terms of hospital readiness for the next accreditation cycle.
Only 37.1% of respondents participated in the Accreditation Canada 2011 cycle, while 53% participated in the Accreditation Canada 2014 cycle and 69.7% participated in that of 2017. A total of 72.7% of respondents participated in the 2017 accreditation cycle for CBAHI. As detailed in Table 2,
Mean scores for subscales revealed that respondents generally agreed with survey items. The subscale on Patient Safety scored highest with an average of 4.17 (SD=0.65). The subscales on Accreditation Impact, Quality Impact and Quality Management closely followed with similar average scores which demonstrated agreement with subscale items. The lowest scoring item was that including Core Questions with an average of 3.79 (SD=0.53).
Interesting observations were found when exploring results for individual items. The majority of respondents (80.4%) indicated that senior executives provide highly visible leadership in maintaining an environment that supports quality improvement and 82.7% indicated that top management is the driving force behind quality improvement efforts and allocate resources for these efforts (75.1%). Responses also indicated that senior executives consistently participate in activities to improve the quality of care and services (80.9%) and have demonstrated an ability to manage the changes needed to improve the quality of care and services (81.1%). According to respondents, senior executives generate confidence that efforts to improve quality will succeed (80.7%), have articulated a clear vision for improving the quality of care and services (83.7%) and have a thorough understanding of how to improve the quality of care and services (83.5%). Moreover, respondents believe that there is critical analysis of the quality management system conducted regularly by senior management (79.0%).
Respondents agreed that the hospital has policies to support quality improvement and programs of care related to accreditation (85.7%) and that the hospital incorporates quality concepts into new services (85.5%). Moreover, the new services are assessed for quality prior to implementation (77.5%) and the hospital maintains records of quality problems they encounter during implementation (87.2%). The hospital also has clearly defined indicators for accreditation (86.1%) and quality objectives that are regularly measured and evaluated (82.6%).
Demonstrated changes were noted as a result of reporting adverse events over the years (85.1%) and hazards and risks are continuously identified and managed in respondents’ departments (85.7%). The hospital also offers staff patient safety training on a regular basis (89.7%) and includes continuing medical education as a component of annual performance appraisal (87%). Respondents also believed that their policies and procedures are effective in preventing errors (90.1%); patient safety is not sacrificed to get more work done (82.2%) and changes are always evaluated for effectiveness (87.5%). The majority of respondents also specified participating in conducting tracers to monitor patient safety goals (73.9%). The hospital provides a climate that supports patient safety (86.6%) and actions of upper management demonstrate that patient safety is a top priority (87.1%).
Respondents indicated that there has been an increase in reporting adverse events (61%) and near misses (57%) over the past few years. The majority believed that the reporting of such events has allowed reviewing procedures to prevent new events with the same cause (85.7%) and reduce their severity (85.4%). Moreover, required organizational practices are regularly monitored for compliance (86.3%).
The overwhelming majority of respondents indicated that the accreditation program is part of the hospital’s strategic plan (92.1%). Respondents also indicated that staff are given enough time to plan and test for quality improvement (76.3%) and that each department maintains specific goals to improve quality and meet accreditation standards (89.4%). The majority of staff indicated that the hospitals’ quality improvement goals are known throughout the unit (84.3%), and they play a key role in setting priorities for quality improvement (86.7%). Respondents indicated that middle managers are as equally involved as staff in developing plans for quality improvement (77.4%) and that they play a key role in setting priorities for quality improvement (85.3%).
Respondents indicated that staff are given education and training on how to identify and act on quality improvement opportunities based on accreditation recommendations (81.8%). Staff are also given continuous training in methods to improve quality management (81.1%) and skills and performance (81%). Only half of the respondents also indicated that staff are offered rewards for quality improvement (50.8%) and 53.4% indicated that they are commended when tasks are done according to policies and procedures. However, 75.4% indicated that inter-departmental cooperation is supported and encouraged. Respondents indicated that the hospital has an effective system for staff to make suggestions to improve quality (69.1%) and that they are given feedback on the changes made based on their suggestions (63.4%) and event reports (67.6%).
When it came to quality results, respondents indicated that the hospital has shown steady, measurable improvement in the quality of services (72.6%), quality of care in different departments and services (83.1%), and quality of services such as laboratory, pharmacy, and radiology (80.7%). The hospital has also maintained a high quality of health services despite financial constraints (76.6%) which they have been measuring through key performance indicators (87.3%) and documented through improvement in patient outcomes (84.6%).
In terms of patient satisfaction, the hospital has shown steady and measurable improvement in that regard (82%) and does a good job in assessing current (83.2%) and future patient needs and expectations (79.3%). Respondents indicated that patient complaints are swiftly met (81.9%), analyzed to prevent the same problem from recurring (82.1%). The hospital also has a formal process for patients to communicate their questions and concerns (76.6%) and uses data from patients to improve services (82.8%). The hospital also regularly assesses patient satisfaction (83.4%) and uses this data when designing new services (75.9%).
When it came to the core questions, around two-thirds of respondents reported stark improvements in requirements and standards between CEBAHI and Accreditation Canada (63%). The majority agreed that the hospital has been working to sustain gains and improvements after accreditation (88.2%). Staff were generally welcoming of the decision to engaged in both local and international accreditation (76.9%) and found it easy to conduct (60.4%). Respondents found it easy to integrate participation in accreditation with general duties (62.7%) and were able to voice their concerns about challenges and difficulties experienced (59.9%). Staff were provided with skills and training when it came to implementing new tasks (81%). Moreover, the hospital has created a quality system that supports implementing changes based on accreditation recommendations (84%) which made the most recent cycles were easier to implement compared to earlier ones (70%). Respondents believed that changes made as a result of accreditation are sustainable (79.9%) and that accreditation is not seen as a one-off activity (77.8%). Although 80.3% of respondents believed that Accreditation Canada standards were feasible to implement while 70.7% reported the same for CEBAHI. Moreover, a total of 87.6% of respondents believed that Accreditation Canada approach and methods of surveying were engaging and sustainable while 78.8% reported the same for CEBAHI.
Respondents indicated that important changes are made in preparation for accreditation (90.8%) and indicated having participated in implementing these changes (85.2%). Recommendations from the last accreditation survey were communicated to staff after the last survey (84%) and were an opportunity to implement important changes at the hospital (86.6%).
As for accreditation benefits, respondents indicated that it has enabled improvement of patient care (86.6%) and motivated staff at the hospital (78.2%). Moreover, respondents indicated that accreditation enabled the development of shared values (80.9%) at the hospital and enabled it to be more perceptive to changes (81.2%). It also enabled the hospital to better use its resources (74.9%), respondent to population needs (79.8%) and partners’ needs (74.6%).
ANOVA results showed a significantly increasing mean score with increasing involvement of respondents in accreditation. This was significant for subscales on Management and Leadership, Quality Management, Patient Safety, Strategic Quality Planning, Quality Results, and Accreditation Impact (Table 3).
No significant difference was observed for respondent involvement in cycles 1 vs. 2. However, it should be noted that the difference was observed for involvement in cycle 1 vs. 4 for the subscales on Management and Leadership (M&L), Quality Management (QM), Patient Safety (PS), Strategic quality planning (SQP) and Accreditation Impact (AI). Significance different was observed for involvement in cycle 2 vs. cycle 4 for subscales on Management and Leadership (M&L), Quality Management (QM), Patient Safety (PS), Strategic quality planning (SQP), and Quality Results (QR). The significant difference was observed between cycles 1 and 3 for the subscale on Quality Management (QM) (Table 3).
ANOVA was constructed to discern difference in response based on which accreditation survey they participated in (See Table 4). It was interesting to observe no significant difference between responses for participation in Canadian vs. CBAHI accreditation. However, a significant difference was observed between participation in Canadian accreditation vs. participation in both types of accreditation surveys with the mean score of the latter being significantly higher. This was observed for the subscales on Management and Leadership (M&L), Quality Management (QM), Patient Safety (PS), Monitoring Patient Safety Goals (MPSG), Strategic quality planning (SQP) and Accreditation Impact (AI).
As detailed in Table 5 below, an analysis of the average subscale score were highest during the Accreditation Canada 2011 survey and started to slowly decrease with subsequent surveys. This was not observed for the subscales on human resource utilization, quality results, patient satisfaction, core questions and benefits of accreditation.
Linear mixed regression results detailed in Table 6 showed an increase of 0.133 (p-value = 0.025) for quality results for every one-unit increase in the subscale on management and leadership. Similarly, an increase of 0.195 (p-value = 0.002) was observed for quality results for everyone unit increase in patient satisfaction. A one-unit increase in the first factor for core questions and benefits of accreditation resulted in respective increases of 0.254 (p-value = 0.001) and 0.177 (p-value =0.001) in quality results.
An increase of 0.163 (p-value =0.028) was observed in accreditation impact for every one-unit increase in management and leadership. A one-unit increase in both factors for Monitoring Patient Safety Goals resulted in respective increases of 0.203 (p-value = 0.009) and 0.100 (p-value =0.014) in Accreditation Impact. An increase of 0.371 (p-value <0.001) in accreditation results was also observed for every unit increase in benefits of accreditation.
A one-unit increase in management and leadership and the second factor on Monitoring Patient Safety Goals resulted in decrease of 0.182 (p-value = 0.015) and 0.088 (p-value = 0.023) respectively in benefits of accreditation. An increase of 0.224 (p-value = 0.003) and 0.248 (p-value =0.001) was observed for benefits of accreditation for every one-unit increase in human resource utilization and quality results respectively. Finally, a one-unit increase in each of the first factor for core questions and accreditation impact resulted in an increase of 0.215 (p-value = 0.014) and 0.331 (p-value <0.001) in benefits of accreditation.
Results from the qualitative component reflected on responses on questions focusing on ways in which changes, and improvements can be sustained, challenges in implementing Accreditation Canada standards and implementing CBAHI standards, differences implementation of Accreditation Canada standards requirements and CBAHI standards, and ways with which accreditation impacted patient outcomes at KSUMC.
- Ways in which changes, and improvements gained after the last accreditation survey be sustained
Most respondents agreed that accreditation provided an opportunity to improve and sustain quality. One respondent indicated that accreditation does improve quality but does not sustain it due to the regression of quality practices after accreditation is achieved. In order to sustain the gains and scale up the improvements achieved so far; several suggestions were proposed. The most recurrent suggestion was building accountability for quality in all hospital employees followed by maintaining, monitoring, evaluating, and improving practices, the establishment of departmental KPI dashboard and empowering departmental quality teams. Leadership commitment, encouragement and support to the quality department were also suggested as a method of sustaining quality. Performing annual mock accreditations and frequent national and international accreditation cycles were less frequent yet significant suggestions made by several respondents. They also recommended recruiting healthcare professionals, integrating more IT services, and increasing documentation. Transparency in the departmental assessment results and developing reward systems for outstanding departments were other key factors in maintaining the achieved gains since they create motivation, friendly competition and enhance knowledge sharing. One respondent also suggested, supporting staff through offering them training and continuing medical education and conducting quality improvement initiatives to improve compliance with the policies and procedures.
While one respondent reported no barriers to sustainability, others mentioned barriers such as staff resistance, the nature of the relationship between the hospital and the university and institutional struggles, such as financial issues and pandemics.
When asked what needs to be done for future accreditation cycles the responses collected identified several different gaps that need to be addressed. The most common response was to sustain the implementation of quality standards, maintain the gains of previous accreditation cycles and guarantee patient safety. Another issue identified by a respondent was the need for longer preparatory phases for each accreditation cycle which would help build up the culture of quality. A need for a more specialized accreditation and to continuously seek alternate accreditations and certification were also suggested by other respondents. Lastly, one respondent mentioned that future accreditations should be modified to ensure the integration of quality in daily hospital practices and strengthen of the culture of quality across the hospital.
When questioned on their performance expectation in upcoming accreditation cycles, all except one respondent believed they would do well due to their experience from previous cycles. Nonetheless, these respondents voiced concern about different issues that need to be addressed. These included finding sources of continuous funding, enhancement of documentation, implementation of standards, the interpretation of policies and procedures, engaging new generations to compensate for the employee turnover rate, and the improvement of the standards and practices of the administration and the human resources office. Additionally, one respondent stated that more attention needs to be given to the patient satisfaction and mental well-being by decreasing the number of beds per room and improving the overall patient experiences through establishing coffee corners and green spaces in and around the hospital. One respondent was pessimistic about future accreditation surveys due to poor compliance with standards between each cycle and stated that pitfalls need to be better addressed to achieve better future results.
- Challenges in implementing Accreditation Canada standards
The main challenge voiced by respondents in implementing international accreditation standards related to limited integration into the regular quality improvement activities taking place. One respondent indicated that such integration was more successful in some departments than in others. Another one of the interviewees mentioned that the institution benefited from the comments and recommendations of the accreditation inspectors and checked how other institutions successfully integrated the accreditation requirements in their routine practices and incorporated them in their own institution. Accreditation resulted in the improvement of quality standards and continuous monitoring of quality outcomes, the modification of the managerial practices, the integration of quality practices into the daily practices and operations, and the communication of quality findings through the quality department. It also resulted in a more quality and patient-oriented hospital management.
- Challenges in implementing CBAHI standards
Regarding the national accreditation, two respondents observed no integration of the international accreditation preparation into the regular quality improvement activities, reported no integration of the national preparation in daily quality activities. However, most respondents did observe such an integration, where many stated that integration was higher with CBAHI than the Canadian accreditation due to the mandatory and systematic nature of CBAHI, and the precise checklists and recommendations it provides. Respondents reported improvement in quality improvement activities, better alignment of daily practices with accreditation requirements and KPIs, better documentation and more professional staff who became more quality-oriented and stopped differentiating between CBAHI and Canadian accreditation. Only one respondent indicated that the integration of the requirements in departments with limited turnaround time was harder due to the similar demanding and time-restricting nature of the CBAHI accreditation.
- Main differences in implementation of international accreditation standards vs. national accreditation standards
With respect to hesitation towards the national accreditation in specific, a debate emerged on the necessity and benefits of obtaining both the national and international accreditations. However, most of the respondents recognized CBAHI as the official national accreditation system. Other respondents realized the impact and benefits of CBAHI which encouraged them to work towards it despite its difficulty and preparation time required. One respondent mentioned that their previous experience with the Canadian accreditation eliminated resistance once the CBAHI accreditation came up. Nonetheless, some mentioned that CBAHI was challenging, and its standards were difficult to fulfill. Some of those challenges included conducting quality improvement initiatives and staff compliance with the hospital safety protocols and procedures and the need to provide them with continuing medical education trainings, in addition to limited financial resources. One respondent indicated that some staff were intimidated with potential layoff as a way of imposing CBAHI accreditation.
When asked about managing CBAHI and the Canadian accreditations during the same year, several benefits and drawbacks were obtained from the interviews. Despite accreditation being challenging and adding to staff workload, especially the clinical services and quality department, almost all respondents would overlap both accreditations again and found that to be more efficient and timesaving and as such, accreditation requirements can be aligned and implemented simultaneously. One respondent even mentioned that it is better to overlap the two cycles every other year. The workload was believed to get easier with time as the employees became familiar with the accreditation requirements and processes. It also gives more time to address the pitfalls between the cycles and allows the hospital to be better prepared for the next cycle. A less common but important reason was that it allows CBAHI to revise the gaps that the Canadian accreditation did not address, since national accreditation is more context specific. One respondent mentioned that undertaking both accreditation surveys simultaneously allow the hospital to be ahead of other institutions and thus have a better reputation.
In contrast to the above, two interviewees preferred separating the two accreditation cycles. The first found aligning the requirements difficult claiming that they were different and preferred not to overlap the two cycles in the future. The second interviewee preferred focusing on the national accreditation first assuming that it is the one to promote the healthcare facility among others in KSA. One respondent was against having the CBAHI accreditation altogether.
- Ways with which accreditation impacted patient outcomes at KSUMC
There were three kinds of responses when asked about the resulting improvement in patient outcomes. The most common opinion was that patient outcomes improved in terms of assessment and evaluation, patient safety, satisfaction and awareness, better patient flow, standardization of medical practice protocols, infection rates, waiting time, cancelation rates, bed occupancy rates, prophylaxis rates, efficient utilization of facilities and more quality improvement initiatives. Another less common opinion was that that although outcomes did improve there was no measurable data. This can only be changed when staff become more patient-oriented rather than focused on documentation. The last group reported no change in outcomes before and after accreditation. This, however, may not be completely accurate and may be the result of lack of outcome recording, monitoring, and followed up caused by limited number of staff.