Striving for Performance Excellence: Ten Years’ Experience & Impact of Accreditation on Quality, Safety, and Overall Performance in King Saud University Medical City (KSUMC) – A Mixed- Methods Study

Maram M. Baksh King Saud University Medical City Yasser S. Amer King Khalid University Hospital, King Saud University Medical City, King Saud University Maher Titi King Khalid University Hospital, King Saud University Medical City Diana Jamal American University of Beirut Abdulrahman Al-Muammar King Khalid University Hospital, King Saud University Medical City Fadi El-Jardali (  fe08@aub.edu.lb ) American University of Beirut


Introduction Objective
The aim of this study is to assess long-term effects of national and international accreditation on continuous quality and patient safety improvement at a university medical city in KSA. Speci cally, this study aims to determine areas of improvement, contribute to lling the evidence gap on the long-term effects of accreditation, and share lessons learned on improving healthcare quality and safety through accreditation.

Methods
We used a mixed-methods approach and triangulated quantitative and qualitative methods and drawing on multiple sources of data including semi-structured interviews with key informants.

Inclusion criteria
The respondents were eligible if they have actively participated in at least two accreditation cycles at the organization over the last 10 years. Two categories of respondents were identi ed. Firstly, the frontline staff who have responded to the cross-sectional self-administered survey. We identi ed our target for the rst category to be 1000 respondents. Secondly, key stakeholders, leaders, managers, and executives who have responded to the semi-structured interviews. These respondents have been selected using purposive sampling of senior managers or directors responsible for strategy and planning, healthcare quality, patient safety, accreditation, and performance management. These interviews have been conducted either as face-to-face interviews or online meetings using the Zoom software as feasible.
Duration of data collection The data collection was launched in February 2020 till May 2021.

Context
This study was conducted at the King Saud University Medical City (KSUMC) that is a tertiary care academic teaching multi-site center with a capacity of 1160 beds and approximately 9000 employees. It is one of the main referral and reference centers in the country. KSUMC has been accredited and reaccredited for three cycles by Accreditation Canada in 2011, 2014, and 2017 and for two cycles by CBAHI in 2017 and 2020. KSUMC is divided administratively into 10 university hospitals and centers. The two largest university hospitals vary in size and location. The rst site has 1060 beds and is a multidisciplinary facility with more than 20 general and subspecialty free medical services providing primary, secondary care, and tertiary care. It includes a designated outpatient and inpatient facility, advanced surgical services and a fully equipped and staffed laboratory, radiology, and pharmacy services in addition to other support services and a dedicated home healthcare program. The second site, that was the rst teaching hospital in KSA, has 100 beds and offers complementary services to the former including mainly ophthalmology and ENT healthcare services.
Quantitative Component

Survey tool
The quantitative tool was adapted from previous studies [14][15][16]. The survey was made available in both Arabic and English and in paper and online formats using Survey Monkey. The adapted survey tool  (See table 2) Demographic questions included gender, age, tenure (at hospital and position), highest educational credentials, and occupational category in addition to respondent participation in accreditation. Some additional open-ended questions were added to the survey request respondent feedback on how to sustain changes resulting from accreditation, challenges they faced in implementing standards (with differentiation between Canadian vs. CBAHI standards), the differences they observed between the two sets of standards, and how accreditation impacted patient outcomes at the hospitals.

Data Analysis
Data were analyzed using IBM SPSS 26.0 and analyses were carried out at the 0.05 signi cance level. 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. Cronbach's alpha was used to measure internal consistency of the subscales. ANOVA was 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. T-test was used to compare subscale scores for each survey cycle (Canadian accreditation 2011, Canadian accreditation 2014, Canadian accreditation 2017 and CBAHI accreditation in 2017). Principal component factor analysis was conducted with orthogonal rotation (varimax) to create factor scores [17]. Eigen values exceeding 1.0 were considered. One factor score was calculated for each of the scales except for those on Monitoring Patient Safety Goals and Core Questions, each of which yielded two factor scores. As mentioned before, the factor scores representing Quality Results, Accreditation Impact and Bene ts of Accreditation were considered dependent variables. Linear regression was used to understand the associations between dependent variables (quality results, accreditation impact, and bene ts of accreditation) with remaining subscales represented by their factors scores.
Qualitative tool A qualitative interview tool was developed targeting key stakeholders, senior leaders and managers from the hospitals who were purposively selected. A total of 15 interviews were conducted. The tool included questions on why accreditation was sought, respondent perception and opinion about the process and features, in addition to the outputs, outcomes and impact of accreditation at the hospitals after particularly after experiencing multiple surveys. The tool also included questions about key challenges and lessons learned in addition to the way forward.
The ve stage 'framework approach' was employed for data analysis [18,19]: Familiarization, identi cation of thematic framework, indexing of the transcripts, abstraction and synthesis through charting and conceptual mapping and interpretation. The thematic framework was de ned by the original research questions and objectives of the study, review of relevant literature, and issues arising from preliminary interviews, plus additional themes of relevance that emerged from the data during the familiarization process.

Quantitative Results
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 re ects a total response rate of 55.3%. As detailed in Table 1  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 con dence 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 de ned 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 identi ed 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 sacri ced to get more work done (82.2%) and changes are always evaluated for effectiveness (87.5%). The majority of respondents also speci ed 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 speci c 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 nancial 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 di culties 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 bene ts, 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 signi cantly increasing mean score with increasing involvement of respondents in accreditation. This was signi cant for subscales on Management and Leadership, Quality Management, Patient Safety, Strategic Quality Planning, Quality Results, and Accreditation Impact (Table  3).  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 signi cant difference between responses for participation in Canadian vs. CBAHI accreditation. However, a signi cant difference was observed between participation in Canadian accreditation vs. participation in both types of accreditation surveys with the mean score of the latter being signi cantly 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 bene ts of accreditation.

Regression Results
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 rst factor for core questions and bene ts 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 bene ts 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 bene ts of accreditation. An increase of 0.224 (p-value = 0.003) and 0.248 (p-value =0.001) was observed for bene ts of accreditation for every one-unit increase in human resource utilization and quality results respectively. Finally, a one-unit increase in each of the rst 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 bene ts of accreditation.

Qualitative Results
Results from the qualitative component re ected 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 signi cant 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 nancial issues and pandemics.
When asked what needs to be done for future accreditation cycles the responses collected identi ed 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 identi ed 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 certi cation were also suggested by other respondents. Lastly, one respondent mentioned that future accreditations should be modi ed 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 nding 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 o ce. 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 bene ted 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 modi cation of the managerial practices, the integration of quality practices into the daily practices and operations, and the communication of quality ndings 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 speci c, a debate emerged on the necessity and bene ts of obtaining both the national and international accreditations. However, most of the respondents recognized CBAHI as the o cial national accreditation system. Other respondents realized the impact and bene ts of CBAHI which encouraged them to work towards it despite its di culty 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 di cult to ful ll. 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 nancial 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 bene ts 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 e cient 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 speci c. 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 rst found aligning the requirements di cult 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 rst 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 ow, standardization of medical practice protocols, infection rates, waiting time, cancelation rates, bed occupancy rates, prophylaxis rates, e cient 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.

Discussion
This study is the rst to examine the long-term impact of accreditation over an extended period in KSA. Results spanned staff perception after ten years of participation in multiple accreditation surveys, both national and international. Study ndings can inform future directions on accreditation in terms of bene ts, impact on quality, strategic planning, and other areas that hospital management can use to create lasting change and tangible improvements. Accreditation is a key component to continuous quality improvement and improving patient outcomes. Accredited hospitals have been shown to outperform non-accredited hospitals and have better overall performance [6]. Participation in accreditation demonstrates organizational commitment to quality improvement and that is a powerful message in today's dynamic health care environment [20].
Result showed consistently improving scores on study composites. Average subscale scores were highest during the Accreditation Canada 2011 survey and started to slowly decrease with subsequent surveys. This nding re ects the high level of both managerial and staff commitment when accreditation was a new concept. However, as the novelty of accreditation wore off, staff became more con dent, the system became more receptive to accreditation requirements and administrative enthusiasm dwindled.
Such a nding is not surprising as studies have documented high performance as hospitals gear up for accreditation. Once hospitals obtain accreditation and the surveyors have left, a sharp decline in performance and a plateau in scores is observed. However, the residual bene t from accreditation remains at up to 90% of performance compared to baseline [5]. It should also be noted that respondents who participated in both national and international accreditation surveys had signi cantly higher scores on survey composites. This re ects on the experiences and lessons gained through repeated exposures to accreditation.
Findings from the survey component re ected varying degrees of agreement on the 11 subscales.
Average scores ranged from 3.68 to 4.06 and while they were not low, they do not indicate high agreement with statements. The scale on human resources utilization and planning had the lowest score across the survey composites. It has been documented in the literature that staff participation in accreditation promotes better clinical outcomes and improves organizational processes [5,21]. As such, it is imperative to incentivize and motivate staff to ensure their buy in and commitment to accreditation.
The qualitative component of the study revealed staff resistance to accreditation as it required them to conduct activities above and beyond their regular work duties. Despite the fact that the hospital was able to secure accreditation from both national and international sources, lasting improvement resulting from accreditation is contingent on staff commitment, engagement and support throughout the process. In fact, evidence shows that some of the barriers to accreditation include lack of staff motivation, low salaries and poor incentives, high workload and staff shortages [22]. Overcoming such barriers require commitment from hospital top management to provide intrinsic and extrinsic motivation measures as the rewards will be reaped in better quality of services, hospital performance, productivity and patient outcomes [22,23]. Staff resistance is believed to be one of the biggest hindrances to implementing accreditation [24], and as such, structural interventions at the organizational level may be needed to create lasting improvements in staff attitudes and behaviors [2].
The issue of human resources utilization is closely linked to management and leadership. While this scale had a higher score than others, it is worth noting that supportive management and visible leadership are critical quality outcomes. This was demonstrated in regression ndings where this scale was signi cantly associated with better quality results, accreditation impact and bene ts of accreditation. Moreover, the qualitative component showed that middle managers and leaders were visibly engaged in the accreditation process. Organizational changes that result from accreditation may contribute to greater managerial autonomy which have been linked to improvement in quality and patient outcomes. Managerial support can improve staff involvement in accreditation and evidence shows that managerial commitment can facilitate organizational change and successful implementation of initiatives such as accreditation [16,25].
Hospital accreditation should be part of a broader organizational strategy that is well planned, consistent and outcome oriented. Such strategies should promote professional development and organizational learning and work on sustainable quality improvement efforts [3]. Organizational learning is not limited to upper management and leaders, it extends to all members of an organization and its success is contingent on open communication and a commitment to team learning [3].
Regular assessments of patient safety cultures are central to quality improvement in hospitals and often an integral component of accreditation requirements [25,26]. Results from the current study showed that the average score on that composite consistently and signi cantly decreased since the rst accreditation cycle in 2011. It is of note that scores on this composite were signi cantly higher for respondents who underwent both national and international accreditation and were also higher for respondents who participated in all survey cycles. Despite this nding, greater investments are needed in strengthening patient safety culture in the hospital as it is crucial for improving overall performance and quality of services [26,27].
Findings from the qualitative component of the survey consistently focused on the mandatory nature of the CBAHI accreditation and the differences between it and the Canadian accreditation. Respondents indicated that CBAHI is more focused on the context of KSA and that the standards are through and at times even more demanding than Canadian accreditation. The fact that CBAHI was mandatory was consistently cited as the main reason for undertaking the process. A review of relevant literature on CBAHI revealed that the standards have a solid focus on quality improvement and patients, they also emphasize the importance of planning and cover important aspects of safety. However, the standards were reportedly believed not to be clearly linked to the health system, lack explicit standards to coordinate risk management activities and did not su ciently involve patients and the community. The standards also lacked measurable element. A comparison to ISQua revealed that the majority of CBAHI standards did not meet or only partially met ISQua principles [9]. Respondents believed that the fact that the hospital started with Canadian accreditation before undertaking national accreditation enabled it to be better to meet its requirements. However, it also appears that the Canadian accreditation lled some gaps that are not addressed by national accreditation which explain some of the strengths identi ed in study results.
Study strengths and weakness should be acknowledged. While this is the rst study to assess the impact of accreditation after several surveys, it utilized a unique survey that built upon previous tools[16] that assessed similar concepts. To test the validity of the tool, the authors used Cronbach's alpha which revealed high scores for all composites. In addition, con rmatory factor analysis showed that all composites loaded on one factor except for those on Monitoring Patient Safety Goals and Core Questions, each of which yielded two factor scores. Another student limitation is a sample size of 630 respondents. However, the majority of respondents participated in two accreditation cycles (83.8%) and the average tenure at the hospital was approximately 10 years. Moreover, although 37% participated in the 2011 accreditation survey, more than half the respondents participated in cycles from 2014 and on. This comes to show the sampled respondents could con dently report on the overall accreditation experience.

Conclusion And Implications
The long-term assessment of accreditation conducted in this study revealed that staff perception about performance was highest during the rst cycle and consistently decreased with consequent surveys. The slight and incremental decrease in scale scores reveal that the bene ts of accreditation were retained.
The qualitative component con rms hospital and staff commitment to accreditation regardless of the accrediting body and the mandatory nature of one over the other. The ultimate goal of accreditation was to improve processes that govern and affect quality of care and patient outcomes. It is also imperative to acknowledge that the earlier accreditation cycles enabled the organization to adapt to the requirements of the national accrediting body despite the vast differences in standards as cited by research evidence and study respondents.

Ethical considerations
The study protocol was approved by the Institutional Review Board (IRB) of the College of Medicine, King Saud University (No. E-19-4096), Riyadh, KSA. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects.

Not applicable
Competing Interests Not Applicable

Con ict of interests
The authors declare no con ict of interests