A mixed-methods study measuring the impact of the hospital accreditation program and the factors for its successful implementation in Madinah

• Main Author: Alsaedi, Abdulaziz Rashed
• Format: Thesis
• Language: English
• Published: 2023
• Subjects: R735-854 Medical education. Medical schools. Research
• Online Access: http://eprints.usm.my/58799/1/01-ABDULAZIZ%20RASHED%20B%20ALSAEDI-FINAL%20THESIS%20P-UD000517%28R%29%20-24%20pages.pdf; http://eprints.usm.my/58799/

Hospital accreditation is recognized by healthcare organizations worldwide as a tool to improve the quality of healthcare, yet there has been an inconsistent impact of this initiative on the quality dimensions. In Saudi Arabia, it has been made mandatory for all Ministry of Health (MOH) hospitals to be accredited by the Central Board for Accreditation of Healthcare Institutions (CBAHI). The aim of the study is to measure the impact of the CBAHI accreditation program on the Institute of Medicine (IOM) quality dimensions, determine the accreditation domains practised in MOH hospitals and explore the enabling factors and solutions for successful implementation of CBAHI accreditation in Madinah. The study applied the mixed-method sequential explanatory design. Secondary data was obtained from five MOH hospitals, followed by a cross-sectional survey among 516 nurses and in-depth interviews with 22 respondents from the five hospitals. The findings revealed that CBAHI had a significant positive impact on safety and effectiveness, while no impact was shown on the efficiency dimension. Strategic quality planning (74.05%), customer (patient) satisfaction (73.45%), and leadership (72.49%) were the most practised domains. The thematic analysis revealed four themes for the successful implementation of accreditation: 1) development of human capital, 2) resolving quality management issues, 3) ensuring availability of resources, and 4) strategizing CBAHI-specific solutions. Finally, the study suggests the following strategies to maintain sustainable improvement in the quality of care i.e., conducting unannounced CBAHI visits, public disclosure, continuous improvement initiatives, and staff recognition and excellence rewards. In conclusion, the CBAHI has a positive impact on the safety and effectiveness of the IOM quality dimension. The proposed enablers and strategies need to be addressed by the policymakers to improve on the efficiency dimension and subsequently ensure effective implementation and maintain continuous improvement of the CBAHI accreditation. Further research is required to expand the current study to other regions or private hospitals in Saudi Arabia.