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Understanding the factors influencing the implementation of accreditation in Jordanian Hospitals: the nurses’ view
  1. Abdullah Algunmeeyn1,
  2. Majd T Mrayyan2
  1. 1Advanced Nursing Department, Faculty of Nursing, Isra University, Amman, Jordan
  2. 2Professor and Consultant of Nursing, Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Zarqa, Jordan
  1. Correspondence to Dr Abdullah Algunmeeyn; abdullahalgunmeeyn{at}


Background Accreditation practices are influenced by many variables, resulting in positive outcomes, such as enhanced motivation among the hospital staff. Motivation among the physician and nurses directly impacts the service quality of the hospitals. Accreditation increases organisational capacity, which may improve hospitals’ overall performance. This study aimed at assessing the factors influencing the implementation of accreditation in Jordanian hospitals.

Method This study employed a qualitative approach. As a result, 40 nurses were recruited from two public hospitals with varying experience and specialties. Data were gathered through face-to-face interviews. Interviews were conducted with a total of 40 hospital nurses, who were selected based on convenience and purposeful sampling.

Results Communication, recruiting qualified and effective hospital directors, patient involvement and engagement and teamwork influenced the implementation of accreditation in Jordanian hospitals.

Conclusion The implementation of the accreditation process is influenced by many factors. Therefore, focusing more on these factors while using the views and experiences of nurses involved in this process will significantly impact the implementation of the accreditation process in various clinical settings, particularly hospitals.

  • accreditation
  • allied health occupations
  • clinical decision-making
  • consumer health information
  • decision making

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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What is already known on this topic

  • Factors influencing the implementation of accreditation have not been studied extensively in hospitals, and there is a lack of research on its implementation in Jordanian hospitals, according to a systematic literature review. Therefore, it is hoped that the results of this study would help health professionals and management set and achieve Total Quality Management standards effectively in this setting.

What this study adds

  • The results of the current analysis have important ramifications for nurses, particularly those in managerial roles. It discusses elements that affect how accreditation is put into practice. Healthcare quality is predicted by accreditation outcomes, and a favourable correlation between accreditation and care quality has been observed. It is necessary to develop strategies to support the ways in which accreditation might boost leadership, culture and atmosphere, which in turn might mediate accreditation performance, and how accreditation might increase patient happiness, patient safety, cost-effectiveness and reputation.

How this study might affect research, practice or policy

  • The current study included face-to-face interviews with Jordanian hospital managers. A review of the inquiry’s findings met the study’s broad questions, satisfying its purpose of researching and recognising factors influencing Jordanian hospital accreditation implementation. Accreditation in Jordanian hospitals was influenced by communication, recruiting qualified hospital leaders, patient involvement and collaboration.


A hospital’s accreditation is defined as the procedures explicitly designed to monitor, assess and improve the quality of care.1–4 The accreditation process is an ongoing and developing quality improvement process that needs continuing attention from all healthcare professionals, especially nurses, as they are in the frontline when it comes to patients’ and quality care.5 Applying accreditation is a vital component in developing contemporary quality management.1 2Accreditation can also assist hospitals in making and tooling procedures that increase patient and staff satisfaction.1 2 4 6

The health industry in Jordan has become much more competitive in recent years.7 Therefore, meeting patients’ expectations and maintaining patients’ satisfaction have become essential.5 8 Total Quality Management in Jordanian hospitals has helped clinical settings to increase organisational capacity.7 Increasing capacity regarding the good, product quality, nurse performance and revenue may improve the hospitals’ overall performance.2 4 6 7 More specifically, accreditation in Jordan focuses on increasing resources to enhance opportunity and revenues for the organisation.7 8 Thus, hospitals must consider efficient use of their resources to maintain the Jordanian health industry.8

Accreditation practices also emphasise improving motivation among the hospital staff.2 4 Motivation among physicians and nurses directly impacts the quality of care in hospitals.9 10 In all hospitals, including the Jordanian ones, accreditation improves organisational performance hospitals based on three pillars. Organisational performances will improve if they focus on quality inspection, quality control and quality assurance.5 Commonly, hospitals in Jordan perform an inspection of quality by getting regular feedback from the patients about service quality. Effective communication strategies will build trust.11 The hospitals can get honest opinions from the patients. It helps the caregiver to identify the specific issue in the medical services. Regular inspection of quality may also help them build a trustworthy relationship with the patients. Once the hospitals find their improved area and improve care quality, controlling and maintaining the quality is necessary. All hospitals are in high competition; thus, maintaining the quality of care has become crucial.7 The public will be assured if hospitals can regularly give satisfactory medical services to the patients. This study assessed the factors that influence the implementation of accreditation in Jordanian hospitals as viewed by nurses. The results will benefit the available healthcare services, enabling healthcare providers to comprehend the importance of accreditation practices.


The study sample

The interviewees in this current qualitative examination consisted of managers in two public hospitals located in Jordan. A total of 40 nurse managers were selected for interview in this study, drawn from two public hospitals in Jordan. These participants included general directors, medical directors, nursing staff and administrators, nursing quality directors and nursing directors. The choice of hospital managers for these interviews was founded on the purposive sampling technique.

The researcher maintained all participants’ privacy and anonymity. Respecting their right to privacy and confidentiality, the identity of those who were interviewed has been withheld. Participants were abbreviated as ‘interviewee N1’ or ‘interviewee N40’, for instance, using a code consisting of N plus the numbers 1–40. Forty hospital nurses were selected for the interviews using purposeful sampling, with a final sample size of 40. The most significant component in selecting and recruiting informants was ensuring that the results could be generalised to other contexts or a larger population by recruiting and selecting informants with a thorough understanding of the issues under investigation.

The research method

In this current study, a qualitative technique was implemented to permit the researchers to understand the subject, thereby deriving sound conclusions.12 A qualitative investigation sources well-grounded, rich descriptions and explanations of processes in identifiable local contexts .13 The research method is one of the main characteristics of the case study method, using several data sources to produce more reliable results than those obtained using a single data source. The types of data collection employed in this study consisted of semistructured interviews as the main data collection tool.

Data collection method

The major data-gathering device used by the researchers was a face-to-face interview. Potential responders were given consent forms and information sheets based on their answers.

The researchers gathered data after finishing the pilot study. With all interviews, permission was obtained from the participants ahead of time for audio recording. Before data collection, the researchers explained their background and goals, discussed research gaps and emphasised how important it was to them that the study was done. The length of the interviews varied slightly, from 35 min to 40 min.

Data analysis

The data from the 40 nurse managers were analysed with the NVivo software package for qualitative data analysis. The audio-recorded interviews were transcribed verbatim, and the transcripts were reviewed before the data were analysed. Later, the data were imported to NVivo to link the concepts contained in the data. This study selected thematic analysis to analyse the data since it was deemed the most suitable technique for this research.


Characteristics of respondents

Forty of the interviewers were above 35 years old, with the bulk having completed their education. They worked in hospitals at various levels and had a collective work experience of more than 15 years, with the majority having 10 to 32 years.

Themes concerning the factors involved in accreditation implementation

The investigation examined the following main subjects, described by the participants in the interviews, about factors that influence Jordan’s accreditation hospitals.


‘Communication’ emerged as the fourth theme from these findings. Communication was identified as the backbone of accreditation implementation in both institutions during the data analysis. Communication, according to the majority of interviewees, is an important instrument for accreditation implementation. The following quotations emphasise this point:

I liked the idea of establishing an intranet network because it would be a very good way to update myself and my colleagues about the accreditation implementation process. Maybe, it would also make it easier for us to access or print out the electronic version (policies, standards, and procedures); to make sure that all the staff in our department read it regularly (interviewee N9).

The hospital established the intranet to make all the necessary policies, procedures, and plans accessible online. The management also intends to upload all accreditation-related material, questions, answers, and presentations to access them whenever they need (interviewee N7).

3.2.2 Patients’ feedback system to improve quality

The second theme to emerge from these findings was ‘patients’ feedback system to improve quality’. A patient satisfaction survey was distributed periodically and aimed to determine the quality of care services provided, which was used to gather information from patients. Its purpose was to enhance patient care quality, satisfy patients’ requirements and expectations, improve healthcare provision and enhance their services. The majority of the participants confirmed that patient involvement through patient feedback to evaluate the quality improvement had facilitated accreditation implementation at both hospitals. These opinions were highlighted in the following quotations from three categories of respondents:

Continuous patient surveys and activities[…] patients and the hospital staff, such as receiving complaints and suggestions from patients and their families (interviewee 5).

That continuous evaluation by patients should be maintained to evaluate the quality of care to meet their needs and expectations. This is how we have applied the Customer Focus technique (interviewee 33).

Patients share to improve our quality of care through a continuous survey, which asks them about the quality of the hospital, and we have an office to receive their suggestions and ideas (interviewee 40).

The technique used in our Hospital is Customer Focus because the hospital management pays most attention to patient satisfaction surveys since they have demonstrated great improvement in the quality of care. For instance, they precisely identify the needs and expectations of the patients (interviewee 21).

The recruitment of qualified and efficient hospital managers

The third factor of implementing accreditation to emerge a theme was qualified and efficient hospital managers. The majority of the interviewees in both hospitals believed that qualified and efficient hospital managers served as a factor of accreditation implementation at their hospital. Therefore, they stated that qualified and efficient hospital managers had facilitated accreditation implementation. It was important to recruit such managers if a hospital achieved success in this area. It is a view that is exemplified in the following quotations:

All Medicine and Nursing managers should gain full awareness and knowledge of health service and hospital management (interviewee N23).

Training […]: managers and decision-makers, in particular, should attend leadership and management courses to increase their skills in hospital management, because most of them have no experience of managing healthcare services and as you know, their background is Medicine or Nursing… (interviewee N30).

Moreover, qualified managers are a key facilitator of accreditation implementation; for example, qualified managers can motivate staff to attain hospital goals and objectives. They will also develop achievable goals and use hospital resources efficiently (interviewee N37).


The fourth factor of implementing accreditation emerged was related to teamwork. The majority of interviewees discussed teamwork, generally about resistance from staff. All interviewees highlighted the role of teamwork to overcome staff’s resistance to accreditation implementation since it is the best way to involve all staff in decreasing resistance and completing the tasks performed. These teams would comprise professionals from all departments, including doctors, nurses and technicians. All interviewees also emphasised the role of top management in teamwork:

We have to calm down resistance to change, as in the case of doctors and some of the other staff. We have to clarify that accreditation implementation is not an instrument of punishment; it is an instrument for learning from experience. We showed them that the hospital is applying it to help them reach their goals in caring for patients. We explained that the advantages of accreditation implementation in the hospital are for the staff and patients, so our higher management has developed a culture of teamwork (interviewee 15).

One of the successful methods of overcoming doctors' resistance during the process of accreditation implementation is that all doctors and other staff in the hospital work as one family focused on achieving accreditation. Although the hospital has a lot of challenges related to the involvement of doctors from outside the hospital in accreditation implementation, due to issues in the hospital’s system, the managers and the top-level administration always encourage our staff to work with them as a team in our hospital, following our systems and focusing on the hospital’s policies and procedures (interviewee 21).

Because the staff was working as a team, they were fully aware of improved working practice and a better work environment; they relaxed and felt supported. Therefore, all of this led to partially overcoming the doctors' resistance to accreditation implementation in our hospital (interviewee N33).


Statement of principal findings

This present analysis discovered that various variables influence the implementation of accreditation in Jordanian hospitals. According to the viewpoint of nurses, many factors were identified, including a patient feedback system to improve quality, the recruitment of skilled and efficient hospital management and teamwork.

Strengths and limitations

However, because the current study was qualitative with only 40 nurse managers from only two public hospitals limited the generalisation of the results. Future samples should include other healthcare professionals rather than only nurse managers.

Interpretation within the context of the wider literature

Different factors influenced the implementation of the accreditation process (Mansour et al). Nurses’ views are important to the accreditation process, resulting in a better process regarding accreditation implementation.1 Enforcing involvement and engagement among patients and communication and teamwork among the staff are essential milestones in accreditation initiatives.

This study found communication to be a factor of accreditation implementation in Jordanian public hospitals. The interviewees in both Hospitals understood it to be the backbone of accreditation culture in their hospitals. It was implied that the top management had made significant efforts in both Hospitals to promote good communication. The participants were able to identify many areas that had improved, such as extensive feedback and a common understanding among all staff. This shared understanding positively affected the accreditation implementation in both hospitals, as supported by other references.14–16 They reveal communication as pivotal to hospital management practice, especially concerning quality programmes. Similarly, effective communication between functions and work units was argued to be critical to ensuring that clients’ demands are satisfied.16 17As a result, an environment of trust and information sharing is formed, creating a shared understanding across functions.

According to the interviewers, hospital managers should be qualified and efficient in leading accreditation implementation. This is most likely owing to the awareness that competent managers can create clear objectives, effective policies and innovative problem-solving techniques. In addition, efficient managers can act as change agents in launching continuous quality initiatives, and, in turn, they will fulfil the hospital’s mission, vision and goals.2 This is consistent with some of the comments made by the interviewees who discussed the efficient use of hospital resources and the importance of good training and leadership. In addition, suitable managers are equipped to develop attainable goals and use hospital resources efficiently.

Moreover, the interviewees highlighted the importance of training programmes related to health service management. These programmes enhance management and leadership skills. These findings are reinforced by studies that show hospital management training programmes are vital for all employees, particularly managers and decision-makers.18–21

In the current study, the findings from both hospitals suggested the involvement of patients (a patients’ feedback system to improve quality) as a factor of accreditation implementation because successful hospitals continually innovate change based on patients’ evolving needs and feedback. It should also be considered that patient satisfaction and the ability to meet patients’ expectations have directly affected hospital performance in both hospitals. It is useful to conduct patient surveys periodically to measure changes in patient satisfaction, and these findings are consistent with other resources.16 22 23It is debated that accreditation depends on patients’ behaviour and the extent of their participation in the care delivery process. Again, this finding (patient involvement via a patients’ feedback system) was unique to this study; it was not found in the literature and required further study).

Finally, the participants’ answers are vital to accreditation implementation.5 These answers are crucial to the success of accreditation implementation in this study. The views of the participating doctors, as declared by several interviewees, teamwork had played a significant role in staff resistance to change, consistent with Raut et al.24 It seems that teamwork enhances the performance of both hospitals and influences the work environment and patient care of the hospital.24 25 Teamwork can help attain better outcomes than the efforts of a single individual. As a result, teamwork will likely produce better and more rapid solutions to any existing problem.18 23 25–27

Implications for policy, practice and research

The current investigation has significant implications for nurses, especially in managerial positions. It addresses factors influencing the implementation of accreditation. Accreditation results predict healthcare quality, and a positive trend between accreditation and quality of care was noted. Strategies are required to reinforce the way how accreditation might lead to improved patient satisfaction, patient safety, cost-effectiveness and reputation, how accreditation might strengthen leadership, culture, climate, and how these factors, in turn, might mediate accreditation performance. Nurses in accredited hospitals feel a higher level of quality of health services. Nurses’ perceptions of the patient safety culture are influenced by nursing management, commitment and supporting strategic quality planning, education and training. Nurse managers’ part of professional healthcare providers to patients and the most energy in hospitals in managing patients comprehensively will continue to increase awareness in enhancing the quality and safety of patients in hospitals. Maintaining or sustaining accreditation is always the focus of the nursing leaders and the organisation; therefore, nursing leaders must empower staff to develop projects for quality improvement and encourage them to participate in quality improvement projects and be involved in decision-making regarding the quality of safe care. The accreditation programme could benefit hospitals, patients and its staff by providing satisfaction, professional development, monetary reward, prestige and honour, indicating globally competitive staff and increasing the quality of care and services of hospitals.

Additionally, various analytical approaches should be employed to investigate the factors influencing hospitals’ accreditation. Thus, managers and policymakers in the Jordanian health sector are urged to:

  • Foster teamwork in Jordanian Hospital. This is particularly dependent on commitment and support from the top management, who can influence the views of participating staff, which is vital for the success of accreditation implementation.

  • The study findings could provide direction and guidance in developing strategies for an effective and efficient accreditation transformation. Hospital managers will find consequently.

Conclusions and recommendations

Many factors influenced the implementation of the accreditation process. Thus, more focus should be given to these factors while using the views of nurses involved in the accreditation process. Considering nurses will result in better implementation of the accreditation process. Enforcing involvement and engagement among patients and communication and teamwork among the staff are essential milestones in all accreditation initiatives.

The current study used a qualitative strategy, which included face-to-face interviews with managers at Jordanian hospitals. Furthermore, a discussion of the inquiry’s findings answered the study’s general questions, meeting the study’s goal of exploring and recognising the factors influencing Jordanian hospital accreditation implementation. Many components, including communication, recruiting qualified and effective hospital directors, patient involvement and engagement and teamwork, influenced the implementation of accreditation in Jordanian hospitals.

The implications of this study

Nurses, particularly those in managerial roles, may benefit from this study. Based on the findings, the authors propose a plan to introduce hospital accreditation in Jordan.

This will be published as a summary box after the abstract in the final published article.

Patient and public involvement statement

There were no patient and public involvement in the design, or conduct, or reporting, or dissemination of this research.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

The Ethics Committees of two Jordanian hospitals provided ethical approval to perform the current inquiry. This study involves human participants and was approved by ID: PHH25110. Participants gave informed consent to participate in the study before taking part.


The investigators acknowledge the invaluable contribution of the research respondents in this study in giving their time and sharing their experiences.



  • Contributors All authors who meet authorship criteria are listed as authors in this article. The listed authors have contributed sufficiently to the work, and they agree with the content of the manuscript. AA developed the study’s conception, literature review, method and discussion, wrote the first and second drafts of the paper, and supervised the whole work. MTM synthesising concept analysis cases of professional autonomy, synthesising cases to fit the concept analysis criteria’ elements, and did the critical revisions accordingly and AA did the whole study’s critical revisions, synthesised the whole parts together, and proofread the final paper. MTM revised the discussion section, wrote the limitations, and did a critical revision to the constructed cases. AA helped integrate the whole parts, final critical revisions, the final editing, and proofreading applied the journal formatting. AA worked and managed journal’s selection and worked as the corresponding author.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.