Health Accreditation through the Perspectives of Auditors

Background: Along with the quick developments in technology, expectations in health care services and attention to quality and accreditation has increased. Objectives: This study aims to explore the perspectives of Health Accreditation Auditors (HAAs) who work for Turkish Health Care Quality and Accreditation Institute (TUSKA) on health care accreditation. Design: In this study, case study method was used. Sample: There are 202 auditors within TUSKA who got their HAA title before 2021 and so far, 57 HAAs have been assigned for active duty in the audits. Materials and Methods: In this study, participants were chosen among the HAAs who attended audits actively via snowball sampling and 15 of them were interviewed. Obtained data were analyzed by MAXQDA. Results: For the purpose of obtaining the perspectives of the HAAs, a list of 17 codes and with the review of these codes, 5 inclusive themes were created. These themes are institutional contribution, institutional development, necessity, �nancial performance and practicality. Conclusions: The HAAs clearly stated that accreditation process contributed to health care institutions positively, accelerated institutional development, proved to be necessary, affected institutions’ �nancial performance positively, and can be implied to any health care institution easily. On the other hand, there were some dissidence among the HAAs on the effect of accreditation on patient potential, perspectives of


Background
Quality, derived from the Latin word "quails" and de ned in different ways, has emerged with the desire to prevent human beings and mechanisms from making mistakes and to reach perfection (Uyguc, 1998).In general terms, quality is de ned as the compliance of a goods or service with all the predetermined features and qualities within the framework of the wishes and desires of the customers (Peskircioglu, 1999).A few de nitions come forward regarding the quality in health care services.Donabedian (1980) de nes quality in health care services as maximizing a comprehensive measure of the patient's well-being after calculating the gains and losses from the stages in the service process.Whereas Ovretvit (1998) de nes it as meeting the needs of those who need the service most in line with the standards and directions set by the top managers and buyers, with the least cost to the institution.
The concept of accreditation has started to appear in the eld of health services since the 1900s, and today it is seen that it is one of the most preferred external evaluation tools in order to obtain information about the level of achievement of the strategically determined targets of health institutions/organizations (Avci and Senel, 2019).The accreditation process in health services is de ned as the process of checking and approving the compliance of health institutions and organizations with previously determined and published standards by institutions whose acceptability is approved by everyone (Kavak, 2018).The aim of accreditation programs in health services is to increase and standardize the quality of the services provided (Cengiz, 2018) Among the studies on the evaluation of accreditation processes in health, we can see that Shaw et al. (2013) carried out a study with the accreditation institution directors and concluded that quality studies in health in the international arenacontribute signi cantly to the improvement of the processes executed in institutions, that the use of traditional systems in order to ensure quality and accreditation practices creates di culties in the process, and that it is necessary to improve standards preventing the process by the accreditation institutions in order to overcome the di culties.In their studies, Boyd et al. (2018) focused on the di culties of hospital audits that accreditation institution auditors go through and they stated that audits put pressure on the hospitals and this ensures improvement in the quality and standards.In addition, they implied that audits, which improve both auditor and institution, are long-termed and demanding process, so auditors carrying out this process should be high quality.Demirbilek and Colak (2008) reported most of the hospital managers support the studies on the quality in health and managers should be encouraged.Akar et al. (2015) stated that better results can be obtained by covering all employees instead of making quality studies seem to be the task of a certain department within the hospital.Ertas and Celik (2018) also reported that quality standards positively affected hospitals.Maimaitireyimu and Arslanoglu (2019) stated in their studies that, with the implementation of accreditation and quality, improvements in service quality as well as customer satisfaction in hospitals were observed, and with the adoption of Health Accreditation Standards (SAS) and Health Quality Standards (SKS) by hospital employees, accreditation and quality procedures became more effective.
With the accreditation services in health, it is aimed to examine health institutions and organizations through an autonomous and unbiased external source.By means of accreditation, it is thought that e ciency will increase, cost will decrease, trust in health institutions and organizations will increase, service quality will improve, management structure will develop and standards or criteria can be met in health services (Timmons, 2004;Yetginoglu, 2009).

Study Aim and Design
This article aimed to examine the perspectives of the Health Accreditation Auditors (HAAs) within the body of the Turkish Health Care Quality and Accreditation Institute (TUSKA), which is the only authorized institution in the eld of health care accreditation in Turkey.In this study, case study method was used.

Population and Sample
There are 202 auditors within TUSKA who got their HAA title before 2021 and so far, 57 HAAs have been assigned for active duty in the audits.In this study, participants were chosen among the HAAs who attended audits actively via snowball sampling and 15 of them were interviewed.

Data Collection
In this study, data were collected via face-to-face interviews employing ve questions in semi-structured interview form.Questions were "Do health accreditation services contribute to health institutions?","Do health accreditation services contribute to health institutions' institutional development?","Are health accreditation services considered to be necessary by health institutions?","How do health accreditation services affect the nancial performance of health institutions?",and "Can health accreditation services be implemented by health institutions?".As well as audio records, the researcher noted down the answers of participants.Each HAA was numbered in the order they were interviewed (HAA1-HAA15).Each interview lasted 27 minutes on average.

Data Analysis
Audio records of the interviews were transcribed and analyzed on MAXQDA by after coding.

Limitations
The limitations of the study are that accreditation practices in health are not widespread enough, studies on accreditation in health services in Turkey are at the beginning level, the HAAs are spread throughout Turkey and it is not possible to meet face-to-face with all the participants in terms of time and budget.

Ethical Considerations
For the conduct of the research, approval was obtained from the Ethics Committee of Non-invasive Clinical Researches at the Faculty of Health Sciences of XXX University, dated 24.11.2021 and numbered 07-2021/34, and permission was obtained from the Presidency of TUSKA with the o cial letter dated 21.12.2021 and numbered 154953729.
A list of 17 codes and 5 inclusive themes were created as a result of the re-examination of the obtained codes during the meetings held to address the perspectives of the HAAs on health accreditation.The inclusive themes created are institutional contribution, institutional development, necessity, nancial performance and applicability.The code tree made from created themes and codes is given in Fig. 2. According to this tree, the most coding was done to 'importance' (36) code under necessity theme, following that code in order are 'managers' (34) code under necessity theme and 'patient potential' (30) code under institutional contribution theme.The least coding was done to 'meeting the standards' (8) code under nancial performance, following that code in order are 'limitations' (10) code under practicality theme and 'personnel development' (11) code under institutional development theme.
The HAA numbers expressing the themes are given in Table 1.In the interviews, all of the HAAs made various statements on the themes of institutional contribution, necessity, nancial performance, and applicability, while 1 HAA did not make any statement regarding the institutional development theme.
The HAA numbers expressing the codes under the institutional contribution theme are given in Table 2.When examined, 15 HAAs statements were made for the patient potential code, 13 for the competitive advantage code, and 10 for the order and brand codes.Considering the codes under the institutional contribution theme, the most stated codes by the HAAs are patient potential (30), competitive advantage (19), order (17) and brand ( 13) codes (Fig. 2).
HAA 1: "When we consider what kind of contributions accreditation provides to institutions, it can be said that it provides a competitive advantage in the rst place.It has now been proven that it provides a competitive advantage especially for health institutions operating in the private sector and adds brand value to institutions." HAA 9: "I can easily say that accredited organizations always make a name for themselves in the sector and create a brand value." HAA 12: "An accredited institution is more organized and neater than another.It works systematically, approachesits services more scienti cally, more technically and more rationally." HAA 15: "They advertise themselves in their working areas, make a name for themselves more, try to become a well-known brand, thus they increase the patient potential in the institution." The HAA numbers expressing the codes under the institutional development theme are given in Table 2.When examined, 10 HAAs made statements about personnel development and belonging codes, and 9 HAAs for team spirit codes.
Considering the codes under the institutional development theme, the most stated codes by the HAAs are team spirit (13), belonging (12) and personnel development (11) (Fig. 2).
HAA 3: "In the accreditation process, those who work with the institution are also improved." HAA 6: "Accreditation also contributes positively to the relations of employees with each other, I have seen this during my audits.Their communication, coordination with each other and working as a team are positively affected." HAA 7: "They come a long way in terms of working, place of work, working culture or belonging to the place of work." HAA numbers expressing the codes under the theme of necessity are given in Table 2.When examined, 14 HAAs statements were made for managers, employees and importance codes.Considering the codes under the necessity theme, the most stated codes by the HAAs are importance (36), managers (34) and employees (27) (Fig. 2).
HAA 2: "In general, there is a resistance to accreditation practices by employees.However, after they start to take part in the process, it is understood by many employees that accreditation is a process aimed at facilitating their own work.I think employees are divided into two on this matter.While many see it as necessary, some see it as unnecessary." HAA 12: "The perception of accreditation in the eld has not been fully formed, there is not enough demand.There are various reasons for this.Various incentive mechanisms can be established to increase demand.The factors that will make the accreditation and process attractive should be increased." HAA 15: "Seeing accreditation as necessary in institutions is partly related to the vision of the manager.Some managers see accreditation as necessary, while others may think it is totally unnecessary." The HAA numbers expressing the codes under the nancial performance theme are given in Table 2.When examined, 13 HAAs statements were made for nancial burden code, 12 for application fee, 9 for income-enhancing effect code and 8 for meeting standards code.Considering the codes under the nancial performance theme, the most stated codes by the HAAs are nancial burden (24), application fee (15), income-enhancing effect (12) and meeting standards (8) (Fig. 2).
HAA 2: "The application fee for accreditation is considered high by most of the health institutions.The application fee may not be high for the private health institutions considering the nancial income after accreditation.However, application fees for accreditation in public institutions can be a challenging reason.Application fees for accreditation should not be reduced, application fees can be met by the ministry for public institutions." HAA 5: "Accreditation creates a nancial burden on institutions in meeting standards.Structural repairs and modi cations are required to meet certain standards.However, I do not think that this nancial burden is very expensive." HAA 10: "Accreditation positively affects the nancial performance of the health institution, even if it does not generate a direct income, it de nitely creates an indirect income for the health institution." HAA 11: "Accreditation costs a lot for health institutions, and health institutions expect a reward for that.This is also very natural." The HAA numbers expressing the codes under the theme of practicality are given in Table 2.When examined, 14 HAAs statements were made for the intelligibility and SAS framework codes and 9 for the limitation code.Considering the codes under the practicality theme, the most stated codes by the HAAs are intelligibility (20), SAS framework (19), and limitation (10) (Fig. 2).
HAA 7: "I don't think there will be much of unintelligibility from the perspectives of the auditors, but sometimes it can happen for the institutions.Standards can be perceived differently." HAA 8: "As a person who takes part in the creation of standards and at every stage of the process, I think the standards are clear and intelligible.As auditors, we do not nd it di cult in this process.However, people who are not familiar with the topic and who are new to the process may have di culty in understanding." Within the scope of the themes discussed in the study, it is seen that the HAAs often differ under the theme of nancial performance, and the nancial structure of the accreditation process draws attention.In the interviews, while some of the HAAs stated that the accreditation process does not cost health institutions and organizations a lot, does not create a nancial burden to meet the standards, and that the application fees are affordable, 11 (73,33%) of the HAAs stated that the accreditation processcosts a lot, especially meeting some of the standards in the SAS brings serious nancial burdens, and that they nd the application fees for public health institutions, if not for health institutions operating in the private sector, quite high, and they have a good number of di culties in affording the fees.

Discussion
Within the scope of the study, 15 HAAs were interviewed, and the perspectives of the HAAs on health services accreditation were discussed.

Institutional Contribution
In the interviews, the HAAs stated that the accreditation process and accreditation certi cate provide various contributions to health institutions, and they discussed these contributions under the headings of competitive advantage, brand, patient potential and order.Regarding the competitive advantage, they stated that the health institutions that take part in the accreditation process and have the accreditation certi cate have an advantage over the institutions that are not involved in this process and do not have the certi cate.Dogan et al., (2017) stated in their study that by targeting quality in health institutions, competitive advantage will be achieved and sustainable success can be achieved in the long term, and the HAAs supported this view in this study.Regarding the brand, they stated that with the successful completion of the accreditation process, the recognition of the institutions will increase, they will create brand value and they will be mentioned more.As patients' perception of the quality of service they receive increases, their satisfaction level is also positively affected by this increase.Many studies show that perceived service quality and level of customer satisfaction signi cantly affect people's recommendations (Uzunal and Uydaci, 2010; Yilmaz, 2011).It is thought that the necessary investments and practices to meet the expectations of the service buyers will provide positive feedbacks and signi cant incomes to the institutions.Increasing the satisfaction of patients in institutions that provide health services is very important in terms of creating customer loyalty (Oz and Uyar, 2014).Regarding patient potential, most of the HAAs stated that accreditation should be a reason for preference.They also mentioned that some of the patients already consider accreditation as a reason for preference and this increases patient potential; however, awareness level of all patients is still not high enough.Regarding order, the HAAs speci ed that accreditation ensures that the processes in health institutions are carried out in a more thorough and reliable way.
Cayirtepe and Ozkoc (2019) discussed the role of having an accreditation certi cate in patients' choice of health institution.
They stated that hospital quality is among the top three in the preference of health institutions, but that the international accreditation certi cate is not given equal importance.That the HAAs mentioned although some of the patients already consider accreditation as a reason for preference, awareness level of all patients is still not high enough supports this view.2020) also supported this view by stating that the accreditation process provides the greatest contribution to health institutions in terms of improving existing processes.In this study, the HAAs also stated that accreditation improves processes and ensures that processes in health institutions are carried out more thoroughly and reliably.It has been seen that the studies in question support each other.

Institutional Development
In the interviews, the HAAs made various statements about institutional development of the accreditation process in institutions.They discussed institutional development under personnel development, belonging and team spirit titles.
Regarding personnel development, they stated that the accreditation process contributes to the development of the institution personnel and that it will contribute to the professionalism of the employees by expanding their vision.Regarding belonging, they stated that with the accreditation process, the staff of the institution feels more belonging to their institution and the commitment between them becomes stronger.Regarding team spirit, they stated that encouraging employees to work together during the accreditation process creates awareness of working as a team and contributes positively to employees' communication.Akyurt (2007) stated in her study that the institutions that received the accreditation certi cate value the ideas of the employees in the institution, the teamwork is given importance by the employees of the institution and there is a sense of belonging, and the vocational training and progress of the employees are supported by their institutions.The results obtained from this study also support this view.

Necessity
In the interviews, the HAAs made various statements regarding the necessity of accreditation.Under the theme of necessity; they discussed the perspectives and approaches of managers and employees to the accreditation process and evaluated the importance given to accreditation.Regarding managers' perspectives on accreditation, they stated that the views of the managers have an important place in the process, along with the managers who know the bene ts of accreditation for the institution and apply for it, there are also managers who see the whole process as a workload and unnecessary action, and this is related to the visionary nature of the managers.They stated that the accreditation process contributes to the development of the institution personnel and that it will contribute to the professionalism of the employees by expanding their vision.Regarding employees' perspectives on accreditation, they stated that the majority of health professionals consider the accreditation process as a workload and do not consider it necessary.Regarding the importance given to accreditation, they stated that the necessary importance is not given to the accreditation process, and that the interest in the accreditation process will increase with the privileges and incentives to be provided.In addition, they expressed the importance and necessity of carrying out activities for more recognition of TUSKA, which controls the accreditation and its process.Akar et al. (2015), in their study on the quality perception of health managers, interpreted the quality management perceptions of managers positively in general.In their study with hospital managers to evaluate hospital accreditation systems, Youse nezhadi et al. (2020) also found that managers were satis ed with the accreditation process and accreditation standards.Yildiz (2010) stated in his study that senior managers can contribute to the creation of an environment aimed at quality improvement and be a driving force behind quality improvement efforts.Mermer (2016) also mentioned in his study that health managers are aware that accreditation is indispensable and that they should include the health institutions they serve in the accreditation process as much as possible.
In his study with the participants from the hospital where he works, Akinci (2016) found that almost all of the participants had a clearly positive attitude towards accreditation; however, one of the obstacles hindering accreditation system requirements results from some of the employees' indifference to the process.Oztas (2014) also supported this situation in her study mentioning that employees should embrace, accept and participate in the accreditation process, emphasized the necessity of creating an adequate institutional culture, and also stated that the Ministry of Health should support quality and accreditation process at all levels.Bayer et al. (2019), in their study to determine the perceptions of health care professionals towards quality, reached a conclusion that quality studies increase the workload of health care professional and do not contribute to their development.
Healthcare professionals do not adopt the accreditation process because it increases bureaucracy, causes loss of time, does not add value to patient care, increases costs both directly and indirectly, and is not consistent (Lemieux-Charles et al., 2003; Green eld and Braithwaite, 2008).
In countries where there is a national accreditation program, health institutions want to know what they will gain from the process, what the process will cost, what it will regulate, what kind of incentives they will receive before they start the accreditation process (Shaw et al., 2010).A study by Braithwaite et al. (2012) supports this statement.It is seen that the policies followed by the governments, the support they provide and the incentives given to health institutions during or at the end of the process are important factors in shaping the process of applying for accreditation of health institutions.
When the results of the studies in the literature are examined, it is seen that the results obtained from this study support each other.

Financial Performance
In the interviews, the HAAs made various statements regarding the effects of accreditation on institutions' nancial performance.The HAAs discussed nancial performance under income-enhancing effect, meeting the standards, nancial burden and application fee headings.Regarding income-enhancing effect, they stated that accreditation increases patient potential, it is effective in reducing expenses and costs, thus it creates an income-increasing effect.Regarding nancial burden, they stated that the accreditation process costs a lot, but this cost is natural and it will pay off in a short time with the implementationsapplied in the process.They also emphasized that these costs are very affordable by private health institutions, but they are generally expensive for public health institutions.Regarding meeting the standards, while some of the HAAs stated that accreditation standards would not create a nancial burden on health institutions, the majority of the HAAs mentioned that meeting the standards in some parts of the set could create a nancial burden on health institutions.
Regarding the application fee, while some of the HAAs claimed that the fee is considered to be too high by most of the health institutions and it is an important factor in applying for accreditation, other HAAs stated that the fee isn't high and it is an unimportant detail for the health institutions.In addition, they stated that the application fees are affordable for the health institutions operating in the private sector, but the fees are high for the health institutions operating in the public sector and the institutions have di culties in meeting them.
In her study, Ozdere (2017)found that accreditation supports effective nancial resource management.Oztas (2014), on the other hand, stated that the costly aspect of quality and accreditation implementations should not be forgotten and necessary precautions should be taken accordingly.
In a study conducted by Maimaitireimu (2019) on the perspectives of quality directors on SAS, the participants stated that they found the accreditation costs of international accrediting institutions such as JCI very high, and that if accreditation activities that are carried voluntarily are made compulsory, it may be too challenging for health institutions to meet the standards nancially.The HAAs in this study also support this view.Jafar et al. (2015) stated that the main obstacle in front of the accreditation process is the inadequacy of nancial resources.Youse nezhadi et al. (2020) supported this view in their study; managers stated that one of the most challenging issues in the accreditation process is de ciencies due to human, nance and equipment (23%).

Practicality
In the interviews, the HAAs made various statements regarding the practicality of accreditation.Practicality was discussed under limitations, intelligibility and SAS framework headings.Regarding limitations, among the HAAs, there were those who thought that the accreditation standards were clear, as well as those who thought they were not, and they also stated that there could be differences of opinion in the perception of the standards.Oztas (2014) stated that quality and external accreditation audits are not adequately carried out, therefore quality and accreditation activities are adversely affected, and standards cannot gain su cient functionality.Regarding intelligibility, they stated that the accreditation standards can be understood by the auditors in general, but from time to time there are di culties in understanding the standards by the executive institutions.Similarly, Akyurt (2007) stated that there are differences of opinion in the implementation of the standards, there are de ciencies in what it means and how it should be applied, and this problemcould be solvedwith trainings by the specialists, which can create a positive effect.

Conclusion
The perspectives of the HAAs within TUSKA on accreditation were discussed under institutional contribution, institutional development, necessity, nancial performance and applicability themes.In the interviews, the HAAs stated that accreditation would make signi cant contributions to health institutions, would contribute to the institutional development of health institutions, that they considered accreditation and its process as necessary, and that the process could be applied in health institutions.However, the HAAs had difference of opinions while evaluating the accreditation process in terms of nancial performance.Opposed to the HAAs who stated that the accreditation process would not create a nancial burden on health institutions and the institutions would not have di culties in meeting the relevant standards, there were also those who stated that the process would create a nancial burden and the institutions would have problems in meeting the standards.The most disagreement among the HAAs arose about the application fee; they evaluated it as high, appropriate and low.However, they commonly stated that the application fee is very affordable for private health institutions and they can easily afford it, but the application fee for public health institutions is high and it is much more di cult to meet the fee.
In order to increase the interest of health institutions in accreditation and accreditation applications, accreditation standards can be revised to create minimum cost to health institutions, various incentives and privileges, primarily nancial, can be provided, and the application fee can be reduced to the minimum or a discounted application fee can be offered for public health institutions.
Code tree.
Weber (2005) stated that if changes occur, accreditation contributes to the hospital in responding to these changes and increasing the quality of service.Braithwaite et al. (2012) stated that accreditation programs continuously improve institution activities and service delivery.Youse nezhadi et al. ( Akyuz and Akyuz (2015) stated that quality and accreditation studies lead to positive changes in communication within the organization.Green eld and Braithwaite (2008) stated that the accreditation process makes positive contributions to communication and decision making.In their study on the use of accreditation as a cultural change tool in hospitals, Pomey et al. (2004) concluded that accreditation is effective in increasing communication and changing the institutional culture.In this study, the HAAs also stated that accreditation encourages the employees of the institution to work together and contributes positively to the communication of the employees by creating team spirit and awareness.It has been seen that the studies in question support each other.

Table 1
The HAA numbers expressing the themes.

Table 2
The HAA numbers expressing the codes under the all theme.