Drivers for the change

Becoming accredited by an international organisation is voluntary in some countries and compulsory in others such as Saudi Arabia and some Gulf countries. Participants in this study indicated that the Ministry of Health was under political and social pressure to accredit hospitals, and this pressure flowed on to them to apply for accreditation. Participants said that despite this push from the Ministry, hospitals genuinely wanted to improve their quality and safety.

The first reason for joining JCI was to achieve patient safety as the JCI focuses on patient safety issues. (PHD, H2)

Accreditation is very important and I am confident that quality means safety. An example of that is the ‘time out’ [during the surgical safety checklist], which was not implemented before the JCI and it was the first International Patient Safety Goal (IPSG) standard to identify the patient correctly. We had sentinel events in most of the country’s hospitals on a daily basis. It happens when a patient is taken to the OT instead of another [OT]. But after implementing ‘time out’, which involves identifying the patient on the table, the events were eliminated. (HD, H2)

Additionally, participants said they thought international accreditation improved their hospital’s reputation among the public. People wanted to be treated at an accredited hospital.

The first benefit we gained from being an accredited hospital is the good reputation as being internationally accredited. (ND, H2)

We became a referral hospital and patients want to be treated in our hospital. Patients’ trust in physician is a proof of their satisfaction. (OTD, H3)

This increase in public trust translated to financial gains for the hospitals.

From my point of view, the only reason for joining the JCI accreditation was to increase hospital’s budget. It was mainly financial and not for organisational improvement (PHD, H3)

Plan for the change

The accreditation process involved a lot of planning by managers. Participants said they had to first familiarise themselves with all requirements for the accreditors’ visit. Next, they invested heavily in resources to comply with the JCI standards and they made organisational structural changes.

The JCI require safety from A to Z such as exit doors, fire extinguishers, and other machines to be connected with an alarm system which was not available before the JCI. (QMD, H2)

A lot of changes have to be made in order to attain accreditation starting with the organisational structure, the leadership design. The leadership responsibility should be clear, clear organisational structure should be in place, design pathways, implementing a system thinking, and leadership commitment towards accreditation. (QM, H3)

Participants said the planning stage for accreditation put significant pressure on both themselves and other hospital staff. The workload was reportedly very high during the accreditation process. This was coupled with workforce shortages and tight timelines to achieve significant changes.

The hardest challenge we faced was the manpower shortage which does not give you enough time to adopt ideas or new work. This required us to work hard and work extra hours to cover this shortage. We worked continuously until 12 midnight until we achieved it. (MD, H2)

While structural changes were difficult to achieve, cultural changes were considered even more difficult. Successful quality improvement initiatives require time, training and resources. Yet participants reported limitations in each of these areas. Participants said they believed If you have qualified staff things will go smoothly (PHD, H1). But getting staff upskilled was difficult within tight time frames, particularly with workforce shortages. So cultural change was slow.

Training must be given in a flexible way and for enough time. For example, heads of departments must be trained for between 3 and 12 months. These trained heads must then be empowered and change those who are non-productive. (QMD, H2)

In cases where participants had skilled, motivated staff the cultural change towards higher quality and safety was quicker and less stressful.

As there are qualified employees who are aware of the JCI accreditation standards, we will be able to deliver better service and reach the highest quality standards of care. (PHD, H1)

Participants noted that cultural change was key to maintaining the quality and safety changes created through the accreditation process.

If you want to improve quality you must first change society and organisational culture. After that you can implement any quality programme through involving all employees. (ND, H1)

The first thing that needed to be changed was the culture of the organisation itself. The people were not familiar with the accreditation process so we needed a total cultural change in the institution regarding the quality and patient safety. (MD, H3)

One way participants motivated staff to work hard and create cultural change within the context of workforce shortages and tight timelines was with financial incentives.

Process of the change

The staff resist the change because they are used to routine work and any new work requires time and effort. (MD, H1)

Making large changes in any organisation can be difficult to achieve. The significant challenges identified by our participants were in the following areas: infrastructure, for example, creating new rooms, emergency exits, relocating services such as pharmacy or radiology to align with accreditation standards; new technological resources associated human resources including electronic medical records, automated pharmaceutical dispensing systems; and new hospital processes for delivery safe care such as the WHO Surgical Safety Checklist.

An example of making change that was time-expensive but valued was changed to medical record documentation. With accreditation, all procedures need to be documented and tracked. Participants said the JCI accreditation process had improved their documentation.

There is a big difference in documentation than before accreditation. You document everything you do which is a good thing itself. Documentation protects you and makes those who come after you start from where you ended. (PTD, H1)

Participants valued such changes because they were evidence-based and could lead to better patient care.

The JCI accreditation standard affects the care because it is evidence-based and people implement it in the right, and scientific way, under the supervision of surveyors who are considered experts in their fields. (ICD, H1)

JCI Accreditation standards were designed to measure performance. Participants valued such measures.

In God we believe, others should bring data, no one could improve what he cannot measure. (QM, H1)

Making the required changes to policies, procedures and department plans came at a cost however: participants said the time hospital staff spent completing documentation in patients’ files was significantly increased, leaving less time for them to spend with patients.

The biggest disadvantage of accreditation is the more documentation it adds to the work. Paperwork increased notably in the presence of shortage in manpower. (ND, H2)

It actually adds more paperwork which in turn affects the time spent with patients. For example, admitting a patient before accreditation took 10 minutes compared to post-accreditation which takes a much longer time because every single thing has to be documented. (PAD, H3)

In terms of making cultural change, as noted above, this was slow and difficult to achieve. Participants found strategies that promoted the kind of cultural change they wanted including involving all employees in the accreditation process.

Employees have to be involved in the process because leaders alone cannot make all changes in the hospital. (QMD, H3)

Participants found these strategies largely effective but they noted some staff were difficult to engage with and motivate to make changes. This was often due to staff having insufficient knowledge of how to apply the accreditation standards to their own practice and because their workloads were so high that they could not achieve change.

The resistance to change was the hardest obstacle that we faced from employees and heads of departments. They did not want to change even for the best which can lead to patient safety. Employees do not concern themselves about outcomes but daily work. The resistance was due to workloads. (ND, H1)

When specifically asked about strategies they implemented to overcome resistance to change, participants mentioned strategies including training, education and force.

We have a very strong management who sent circulars to all departments and forced people to comply through appointing strict heads. (ICD, H3)

Staff resistance was overcome by education and training and they were involved in the process making because they are directly dealing with these process and standards. (ND, H3)

The culture of instilling change in people was a bit difficult but we could do it by regular education of people, regular communication at all levels like doctors, nurses and technicians. (MD, H3)

Maintaining changes post-accreditation

Achieving accreditation was hard work. However, maintaining the level of performance achieved during accreditation was—in some cases—even harder. To maintain changes post-accreditation participants described embedding monitoring strategies with regular staff surveys, committees and the documentation and evaluation of particular processes. These strategies were largely reported by participants in middle management. Top management was less engaged.

The follow-up by the top management decreased after achieving accreditation which caused a drop in performance. A follow-up from the top management is required in order to continue at the same level we achieved during accreditation. (PTA, H2)

Resources were available during accreditation process but discontinued immediately after achieving accreditation, which affected the continuity of care. For example, whatever we requested during accreditation we got immediately but not after achieving accreditation. (ND, H1)

Top management commitment is the most important principle of quality. I read this and did not believe it until I saw it myself and started believing it is the only solution to quality. If you want to implement quality, you need a management who believes in it. (QMD, H1)

Top management should motivate employees financially to maintain quality. (PH, H1).

Management tried different approaches to encourage staff to maintain accreditation changes. Some participants said they used financial deprivation and appointing very strict department heads to motivate staff to maintain changes.

We as a quality management department used the accreditation to threaten employees that they would not be included in the excellence allowance list if we failed accreditation or re-accreditation. (QMD, H2).

From my point of view punishment is the best way that helped us get back to the performance reached during accreditation. (MD, H1)

We have a very strong management who sent circulars to all departments and forced people to comply through appointing strict heads. (ICD, H3)

Other participants used financial rewards to encourage staff to maintain changes.

Employees were rewarded, especially those who worked hard during and after accreditation. Also their names were listed among those eligible for excellence allowances this year which is 10% of their basic salaries, in recognition of their efforts. (ND, H2)

Incentives aside, participants faced the very real problem of maintaining a workforce capable of maintaining the changes. Accreditation put work pressure on hospital staff, and this pressure eventually led some hospital processes to deteriorate.

Maintaining performance after accreditation is harder than achieving it. The reason is the lack of continuity due to healthcare professional shortage. This shortage is due to vacations or resignations for unknown reasons. (MD, H1)

We have a problem that the experienced employees are resigning and new ones are coming and we have to teach them again and again so that they will reach the same level. (ND, H3)

I noticed a drop in performance in my department after we achieved the JCI accreditation. Medication errors have increased after accreditation due to not complying with standards. (PHD, H1)

To mitigate this, participants said continuous staff education was key.

We have a quality department that has strategies on how to maintain performance after accreditation. These strategies included training and education of all employees on quality aspects. (PA, H3)

We have to educate employees to keep them all at the same level as their counterparts. There is annual training in quality and patient safety for all employees, refreshers for the existing employees and induction courses for the new ones. (QMD, H3)

Again, the education was sometimes coupled with punitive strategies for those not attending.

Attendance for lectures and training was high because it is mandatory. If you did not attend, you had to give an excuse and they would schedule you in another one. There was also punishment for those not attending. (PAD, H3)

Maintaining change was difficult to achieve in the context of staff turnover occurring at the top and middle management levels.

Patient issues

Participants described the importance of their accreditation processes in terms of patient safety and quality of care. This final theme explores their prioritisation of patients in their narratives of accreditation. First, participants reported that patients motivated the initial plan for their institution to gain accreditation. Once accreditation was gained participants reported higher patient engagement, more patients accessing their services and improved patient outcomes.

Medication errors decreased such as dispensing errors, prescribing errors from doctors, and administration errors. We compared the number of errors before and after accreditation and noticed improvement after accreditation. (PHD, H1)

Regarding patient safety, we have indicators of morbidity and mortality, sentinel events, near miss, and medication errors and noticed improvement in all indicators after accreditation. (HD, H2)

Patients reported higher rates of satisfaction and participants genuinely thought this was based on improvements in the quality of care their hospital was providing since gaining accreditation. However, as time progressed, performance sometimes dropped and according to participants, this was due to both increased number of patients needing care and difficulties in maintaining accreditation changes.

There is an increase in the number of patients which is an important reason behind a drop in performance, which I considered positive and negative at the same time. This increase is due to patients' willingness to be treated in our hospital or transferred from other hospitals. On one side it reflects the good reputation the hospital achieved after accreditation, and on the other side it impacted the continuity of care and caused drop in performance. (HD, H2)