Alsaedi, Abdulaziz Rashed
(2023)
A mixed-methods study measuring the
impact of the hospital accreditation
program and the factors for its
successful implementation in
Madinah.
PhD thesis, Universiti Sains Malaysia.
Abstract
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.
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