Key Performance Indicators (KPIs) for healthcare accreditation

system
Dila Agrizzi
Ebrahim Jaafaripooyan
Faizollah Akbarihaghighi

Abstract

Purpose This paper aims to propose valuable performance indicators for evaluation
of an accreditation programme, as an effective external assessment scheme in health
care.
Design/methodology/approach The paper is based on an exploratory research
which has used semi-structured interviews to collect data from a number of health
care accreditation experts. The respondents were selected from different universities
and accreditation-associated institutions in developed and developing countries
including Iran. They were chosen through snowball sampling technique.

Findings Thematic content analysis of the data provided the following key
performance indicators (KPIs) which are hoped to be influential in evaluating the
performance of healthcare accreditation programmes. For example; the effect of
accreditation in a society, cost of accreditation for all participants (e.g. hospitals,
accrediting bodies), tangible improvement in the outcomes of patients care or
satisfaction after accreditation, satisfaction of different stakeholders with the
accreditation results, and a focus on features and requirements of local health care
economy by accreditation programme.
Originality/value This study is deemed to be unique and novel at ascertaining a
number of invaluable dimensions for evaluating the performance of accreditation
programmes in public sector, specifically health care. It has sought to contribute to the
knowledge in the area of performance measurement and improvement in the public
sector.

Keywords Accreditation system, Health care, Performance measurement and

improvement
1

Introduction

Accreditation is argued to be one of the most influential systems for assessing and
improving the performance of service delivery processes in health care (Hirose et al.,
2003, Nandraj et al., 2001). The term accreditation reflects the origins of systematic
assessment of hospitals against explicit standards (WHO, 2003). It has been defined
as an external evaluation mechanism which assesses the performance of healthcare
organizations (HCOs) through investigating their compliance with a series of preestablished standards aiming at continuous improvement of quality rather than simply
maintaining minimal levels of performance (Pomey et al., 2005, Shaw, 2004a). It is de
facto public recognition emanated from the achievement of accreditation standards by
a healthcare organisation, which is demonstrated after an independent external peer
assessment of the organisations performance (Shaw, 2004b).

It has been emphasized that the accreditation owns a number of specific features that
make it more preferable for regulators, providers, third parties and customers to rely
on than other existing quality measurement and improvement programmes, such as
ISO and EFQM, in health care (see for example, Australian Council on Healthcare,
2003, Heaton, 2000, Roa and Rooney, 1999, Shaw, 2000). The main characteristics,
as have been mentioned frequently in the literature (e.g. Scrivens, 1997, Donahue and
Vanostenberg, 2000, Heaton, 2000, Shaw, 2000), briefly include:
Performing a comprehensive assessment of healthcare organizations;
Suiting healthcare peculiarities because of originating from this sector;
Containing improvement besides mere review aspects; and
Assessment by trained and healthcare oriented surveyors

Although the accreditation scheme itself performs an evaluation of HCOs, its

performance also needs to be assessed in case it may go beyond its initially
determined objectives and does not detect defects and malpractices (Scrivens, 1993,
Shaw, 2003). Despite this obtrusive necessity, the argument remains that research into
accreditations performance and effectiveness is still at an embryonic stage
(Braithwaite et al., 2006, de Walcque et al., 2008).
According to de Walcque et al. (2008), despite considerable amount of money spent
on hospital accreditation programmes, researchers have established a paucity of
2

evidence upon the effectiveness of this scheme. Therefore, owing to the dearth of
studies focused specifically on establishing performance dimensions for an
accreditation scheme, this paper attempts to explore a number of key performance
indicators (KPIs) for healthcare accreditation programmes. These dimensions are
intended to present a generic and practical framework for assessing the performance
of these programmes. This paper is structured as follows. The first section reviews the
related literature concerning the performance measurement of the healthcare
accreditation (e.g. Pongpirul et al., 2006, Greenfield and Braithwaite, 2007). The
second section is devoted to describing the research methods employed in this paper.
The empirical findings are presented in the next part, followed by discussion and
conclusion in the final section.
Background

A variety of studies have called for research into accreditation effectiveness and
performance measurement (see for example: Mays, 2004, Ovretveit et al., 2002,
Braithwaite et al., 2006, Pomey et al., 2004, Shaw, 2001, Shaw, 2003, Walshe et al.,
2001, vretveit, 2005). Two distinctive avenues for evaluating accreditation
programmes have been mentioned (Scrivens (1997, p.6). The first is the objective
indicator approach, in which tangible measures of success, mainly in the form of
performance indicators, are developed or extracted from reviewed organizations. In
the next step, an attempt is made to establish and examine a relationship between the
accreditation and those indicators. Within this approach, any change in the quality of
services delivered by accredited HCOs is investigated and the positive changes are
tried to be attributed to the proper and effective function and performance of the
accreditation programme and seen as a confirmatory sign of the accreditations impact
on the organizations. The second way is called the experience or perception
approach, in which perceptions of different groups, involved or related to
accreditation, are elicited relative to accreditations functions or components
(Scrivens, 1997, p.6). Both of these approaches have their own strengths and
weaknesses. Whilst perception approach is accused of being mostly superficial and
judgmental (Scrivens, 1997), criticisms about first approach in the literature are
mostly in connection with difficulties of measuring performance in health care (see
e.g. Eddy, 1998).

As for existing studies concerning the performance measurement of accreditation

schemes, different types of attempts and initiatives have been made in the same line
with Scrivens approaches. Some studies have looked into the relationship between
accreditation and clinical indicators (Collopy, 2000, Williams et al., 2005) or patient
satisfaction (Heuer, 2004) and providers satisfaction (Al Tehewy et al., 2009).
Braithwaite et al. (2006) have investigated the relationship between accreditation
status, namely accredited or non-accredited, and clinical performance in a prospective
study. By the same token, another category of studies have concentrated on different
groups

of

professionals

perspective

upon

accreditation

performance

and

effectiveness; for instance, Baker and Dunn (2006) in the education sector and Hurst
(1997), Jaafaripooyan (2003) and Pongpirul et al. (2006) in health care. In their
studies, Hurst,(1997) Jaafaripooyan and Pongpirul et al. solicited professionals such
as hospital staff, accreditation managers, surveyors and clinicians to provide their
opinions on performance of their running accreditation programmes in terms of the
accreditation standards, surveyors and implementation processes. In a seminal work
on the performance of accreditation programmes, International Society for Quality in
Health Care (ISQua)[1] has published a series of standards and principles for external
evaluation organizations in health care which can be used by all the organizations for
improving and assessing the performance of their programmes (ISQua, 2007b,
2007a). However, because of the importance of accreditation programme in ensuring
the quality of health services (Shaw, 2001, Jovanovic, 2005, Dickson and Nicklin,
2008) and in response to increasing and multiple concerns about ensuring quality in
health care sector (Ovretveit and Gustafson, 2002), the endeavours for finding a more
effective mechanism or innovative way for evaluating accreditation performance has
not been thus far stopped. This paper has sought to build up a framework composed of
a number of key performance indicators (KPIs) for assessing the performance of
healthcare accreditation programmes in order to contribute to the current knowledge
in performance measurement and improvement in public sector and specifically health
care.

Methodology

This paper is based on an exploratory research approach which has utilised the
interview method in order to collect related data. Around 30 experts of healthcare
accreditation from several universities (from a number of countries) and accreditation
4

related institutions, such as Joint Commission on Accreditation of Healthcare

Organizations (JCAHO), Australian Council on Healthcare Standards (ACHS) and
International Society for Quality (ISQua) in health care were interviewed by email
during three months starting from May 2008, of which twenty experts replied. A
purposive sample, also known as judgement sample and the most common sampling
technique (Marshall, 1996, p.523), was selected from the potential participants. This
study adopts a rich sample to examine the issue and build further understanding of
performance measures in healthcare. Inclusion criteria were developed based on
participants publications (i.e. mainly books and papers in the accreditation-related
referred journals at first stage). Although there was no asserted limitation and
mandate for selecting experts from a specific country, experts from those countries
which have comparably settled and successful accreditation programme (such as the
USA, Canada, Australia, the UK and France, and a couple of interesting developing
countries such as Iran. A snowball sampling technique was used at later stage in
order to select additional experts in a way that, at the end of the interview, the
respondents were asked to identify all other accreditation related experts who are able
of answering the questionnaire (Marshall, 1996, p. 523).

Since respondents were geographically located in several parts of the world,

conducting a conventional interview could be highly expensive and time-consuming,
so the email interview technique (Foster, 1994) was adopted in this study. The main
reasons for selecting this technique specifically were:
Potential participants, as mentioned earlier, were spread out in different countries
and not limited to a country or an organization.
Given their time limitation, this way was convincingly useful because they could
respond in their own time and without any pressure, which might impinge on the
quality of their responses.
They all were supposed to have sufficient access to the internet because of their
position and job. This proved to be the case at the later stages of the research, as
all respondents replied to the emails.

Potential advantages of this technique, some have been mentioned below (Foster,
1994, p. 93), has made it highly capable for fulfilling the objectives of this study.

Electronic mail is far less costly than physical mail, telephone or personal
interview

A questionnaire or standard interview schedule can be sent to many recipients

at once, irrespective of geographical location or time-zone

There is no need to make meeting arrangements beforehand

The questionnaire or schedule remains available to respondents until they are

ready to answer

They can also decide whether to participate or not, and if they contribute, the
timing is completely at their discretion

The responses come back in a form which is fairly polished and readable

The respondents were asked to answer open-ended questions (Silverman, 2005)

concerning the main performance dimensions of an accreditation programme and
prioritization of the dimensions based on their importance and prominence in
evaluating an accreditation programme in health care. The main purpose of the
questions was to establish the key factors and indicators for conducting a
comprehensive evaluation of a healthcare accreditation programme. The questions
were also followed by a statement obtaining respondents other related comments.
Two follow-up emails were sent as reminders to those of respondents who did not
respond within the deadline. This raised the response rate remarkably. Further emails
were exchanged in order to clarify any ambiguity that emerges during the
communications in their responses. Data analysis was conducted using conventional
content analysis technique whereby the main categories of themes indicative of
accreditation KPIs extracted (Holdford, 2008, Gillham, 2000, Pope and Mays, 2006).

Findings and Discussion

Various themes surfaced after organizing, consolidating and analyzing the data from
the questionnaires and the participants follow-up responses, which formed, in turn,
the dimensions (tables 1 to 4). The resultant dimensions are anticipated to give a
rather clear picture of the performance and quality of accreditation programmes in
health care, from the perspective of experts interviewed in this research.

Accreditation is one of the most known and applicable methods for assessing the
performance of healthcare organizations and ensuring the quality and safety of care
delivered to patients (Jovanovic, 2005, Sunol et al., 2009). However, performance
assessment of this system itself has not been considered as much as its applicability
and popularity in health care and only a few studies (e.g. Scrivens, 1993, Braithwaite
et al., 2006, Luptom and Doran, 2006, Rooney and Barnes, 2001, Al Tehewy et al.,
2009, Greenfield et al., 2009) have embarked on examining the performance of
accreditation and various adopted approaches to this evaluation process (Greenfield
and Braithwaite, 2009, Sunol et al., 2009). Most of those approaches have relied on
the outcomes of accreditation programme in terms of its impact on the hospitals
services, such as Rooney and Barnes (2001), Luptom and Doran (2006) and Al
Tehewy et al. (2009). However, assessment of accreditation performance in that way
has not been a straightforward and reliable process owing to difficulty in measuring
long-lasting, probable and intangible outcomes in health care (Eddy, 1998, Loeb,
2004, de Bruijn, 2002). As such, Ovreveit and Gustafsun (2002) have articulated that
it is difficult to prove that the outcomes in health care are due to a specific programme
or intervention and not to something else, because of peculiarities of health care.
Therefore, because of the complex nature of the sector, there is much more inclination
to utilizing perception approaches (Scrivens, 1997, Pongpirul et al., 2006), and to
resorting to related and knowledgeable or involved people for identifying pertinent
dimensions and assessing the performance of accreditation programmes. The
approach of this research, i.e. appealing to experts perspectives, could provide a
generic range of dimensions which are hoped to be useful for evaluating the
performance of accreditation programmes in different contexts, specifically health
care. The identified dimensions are presented in four tables (1 to 4) on the basis of
their relevance to different aspects of accreditation.

Table 1 demonstrates those dimensions reflecting the overall effects of an

accreditation programme in a society. For instance, the rate (percentage) of hospitals
which meet the requirements (achieve an acceptable level) of an accreditation
programme where all hospitals are obliged to participate and apply for accreditation,
as in France (Giraud, 2001) and Italy (Shaw, 2006). As such satisfaction and retention
rate of hospitals towards a voluntary accreditation programme may also give valuable
insights of the effects of accreditation programme. Stakeholders satisfaction and
reliance on accreditation results can be an important indicator of accreditation
7

acceptability in a society, given the fact that in health care due to an information
asymmetry between consumers and providers (Montagu, 2003), stakeholders are more
amenable to rely on such programme.

Table 1: KPIs concerning the effects of accreditation programmes in a society

- The percentage of hospitals which meet the standards of (mandatory)

accreditation
- The percentage of failed hospitals which subsequently are successful by
calculations of (mandatory) accreditation
- Demand for (voluntary) accreditation (i.e. uptake of hospitals)
- The level of community awareness of the accreditation programme (a measure of
accreditation broad acceptability and credibility)
- Satisfaction and retention rate of hospitals with the (voluntary) accreditation
programme
- The degree of stakeholders reliance on accreditation results in making pertinent
policies and decisions
- Satisfaction of different stakeholders with the accreditation results
- Consideration of priorities, features and requirements of local health care
economy by accreditation programme

The second groups of KPIs are concerned with the nature of accreditation survey and
standards (table 2). As to surveyors, Greenfield et al. (2008) refer to surveyors as a
core part of a health care accreditation program to an extent that they take surveyors
into account as the eyes, ears and hands of any accrediting organisation, without
which the accreditation process is unsustainable. Therefore, the importance of this
group as the executable arm of an accreditation programme is overly obvious.
According to Greenfield et al. (2009) reliability for an accreditation programme might
be achieved through employing a detailed training program with mentoring for new
surveyors and defined surveyor selection criteria.

Standards are a main part of accreditation systems, against which HCOs are assessed.
The primary objective of these standards is to improve safety, effectiveness, cost and
efficiency for the benefit of the whole community (Scrivens, 1995). de Walcque et al.
(2008) point out that use of standards is an important way for systematically
reviewing a complex system and measuring improvements in the processes of
delivering health services. Therefore, it is important that the standards are
concomitantly reviewed and keep pace with improvements in care and remain
relevant to the service or organization which is being measured. There are various
dimensions also should be heeded while evaluating accreditation standards. For
instance the rate of clarity and feasibility of standards for healthcare organizations
implies that standards at first sight should be understandable for those who perform
accreditation (i.e. surveyors) and whom are being accredited. As a case in point,
Accreditation Canada [2] believes in optimal, but achievable (within the current state
of the art) and surveyable standards within the confines of resource constraints.
Application of a consensual process for developing the standards is also another
important KPI which is recommended by experts. Incorporation of stakeholders
voice in different stages of accreditation programmes is receiving growing attention
among accreditation agencies, see for example O'Connor et al. (2007). Inclusion of
clinical indicators in the accreditation standards has increased the clinician
involvement in different stages of the accreditation process (Collopy, 2000). The
existence of a regular review and update system for whole process of accreditation
programmes, specifically the standards, is widely reflected. In JCAHO, standards are
reviewed every year for hospitals and every two years for other HCOs and
Accreditation Canada reviews its standards every two years. Interview, documentary
9

analysis and observation are three main methods used for undertaking accreditation
and gathering required data concerning HCOs improvement practices. Accordingly,
an emphasis on documenting by HCOs in accreditation standards could be a KPI for
evaluating the appropriateness of accreditation standards.

10

Table 2: KPIs for Accreditation Survey and Standards

- The rate of using trained and health-care oriented surveyors

- Examination of surveyors selection and training processes
- Appraisal of surveyors performance
- A sound and reliable scoring system
- a significant input from all stakeholders (e.g. providers of care, consumers and
purchasers, government, insurers and healthcare administrators) into standard
development process
- The existence of a regular review and update system for the standards and the
frequency of reviewing and updating process
- The rate of clarity and feasibility of standards for healthcare organizations
- The degree of reflection of local/national/international healthcare expectations
and criteria in accreditation standards
Robust accreditation standards which are developed by consensus
- The rate of inclusion of outcome related metrics in accreditation standards
- The rate of inclusion of clinical indicators in the standards
- The scope of the standards, i.e. the rate of covering all services and activities in
accreditation, e.g. inclusion of both clinical and non-clinical services
- More attention to structure and process standards, as compared to outcome
indicators, for accreditation in developing countries
- Communication of standards (especially meaning and interpretation) to all
participant groups (e.g. organizations to be accredited, surveyors) before
accreditation
- The rate of consideration of documenting requirements in accreditation
standards.

11

The other group of the KPIs relates to the outcomes accreditation programmes are
supposed to generate the HCOs indicated in (table 3). There is evidence from the
literature indicating a link between accreditation and improved healthcare outcomes.
For example, Sunol et al. (2009) quote from those directly involved in the
accreditation projects, that accreditation can contribute to improving health care and
service quality. Similar claims are made by Chen et al. (2003) and Devers et al.
(2004). The latter authors found that a quasi-regulatory organization (e.g., JCAHO)
can be a primary driver for hospitals patient-safety initiatives. However, the
existence of such a connection has been also doubted (see for example; Griffith et al.,
2002, Beaulieu and Epstein, 2002, Grasso et al., 2005, Snyder and Anderson, 2005).

Table 3: KPIs in relation to the outcomes of an accreditation programme

- The number of distinctive actions taken by a hospital following a survey or

accreditation decision to meet the requirements.
- Tangible measures of improvement in patients satisfaction and care outcomes
after accreditation
- The level of HCOs compliance with accreditation requirements
- The rate of achievement of accreditation programme to its pre-determined goals
- Improvement in accredited hospitals over time (pre/post accreditation) or in
accredited/non-accredited hospitals in terms of following indicators:

Improved patient outcomes and patient/family satisfaction

Improved staff satisfaction and lower turnover

Improved financial performance

Improved communication and organizational culture

Increased standardization of processes

Greater safety for patients and staff and fewer adverse events

Table 3 exhibits the dimensions for tracing the impacts of an accreditation programme
on HCOs. Actions taken by accredited organizations following evaluation by the
12

programme may direct towards identifying the real impact of accreditation on HCOs.
These dimensions can give a clearer picture for measuring the usefulness of
accreditation programmes. Table 4 finally displays valuable indicators intended to
judge the overall nature of accreditation programmes. Transparency of all stages of
accreditation programme for public and those under assessment and responsiveness of
these programmes for their decisions can turn them into an evidence-based
programme (Greenfield and Braithwaite, 2009). Flexibility of an accreditation
programme to changes in the environment and to the feedback of different
stakeholders may maintain its sustainability and relevance.

Table 4: KPIs regarding overall nature of an accreditation programme

- Responsiveness and accountability of an accreditation programme

- Consistency and transparency of accreditation programme
- Comprehensiveness and flexibility of the accreditation programme
- Cost of accreditation for all participants (e.g. hospitals, accrediting bodies)
- The use of a self-evaluation system by the accreditation programme to ensure its
continued relevance to current practice

As for the prioritization of the performance dimensions (except for very few
respondents who considered dimensions such as inclusion of patient safety and
outcome indicators in accreditation standards much more important in accreditation
of hospitals), most of the interviewees were of the opinion that it is difficult to
prioritize the performance dimensions. Some stipulated that it is a sort of political
decision to prioritise the dimensions based on their importance, because the
dimensions may become important given local priorities or policies. For instance, one
interviewee mentioned:

I am of the view that they [accreditation performance

dimensions] cannot be ranked or prioritised; such thinking is contrary
to the continuous quality improvement model that informs accreditation
13

programs. [For example] the cleaning and disinfecting of beds is as

important as the sterilising of surgical instruments

Final Considerations

With the paucity of studies working specifically on dimensions concerning

accreditation performance, this study has brought together a number of generic and
instructive indicators, which might be utilized for assessing performance of an
accreditation programme, particularly in health care. However, as mentioned earlier,
these performance measures are mostly general pathways and guidelines, which can
be sub divided into more specific indicators. Even so, this study can be conceived as
unique and novel at ascertaining number of invaluable dimensions for evaluating the
performance of an accreditation programme in health care. It has sought to contribute
to the knowledge in the area of self evaluation and external performance measurement
in public sector. Nonetheless, additional and incessant empirical research is necessary
in order to build further understanding of accreditation system and the impact of its
application on society.
Notes:
1. ISQua is a non-profit, independent organisation which works to provide services to guide health
professionals, providers, researchers, agencies, policy makers and consumers, to achieve excellence in
healthcare delivery to all people, and to continuously improve the quality and safety of care (ISQua
website).
2. Canadian Council on Health Services Accreditation which is now called Accreditation Canada

14

Reference:
AL TEHEWY, M., SALEM, B., HABIL, I. & EL OKDA, S. (2009) Evaluation of
accreditation program in non-governmental organizations' health units in
Egypt: short-term outcomes. International Journal for Quality in Health
Care, 21, 183.
AUSTRALIAN COUNCIL ON HEALTHCARE, S. (2003) The ACHS
Evaluation and Quality Improvement Program.
BAKER, S. & DUNN, D. (2006) Accreditation: The Hallmark of Educational
Quality. Radiol Technol, 78, 123-130.
BEAULIEU, N. D. & EPSTEIN, A. M. (2002) National Committee on Quality
Assurance health-plan accreditation: predictors, correlates of
performance, and market impact. Med Care, 40, 325-37.
BRAITHWAITE, J., WESTBROOK, J., PAWSEY, M., GREENFIELD, D.,
NAYLOR, J., IEDEMA, R., RUNCIMAN, B., REDMAN, S., JORM, C.,
ROBINSON, M., NATHAN, S. & GIBBERD, R. (2006) A prospective,
multi-method, multi-disciplinary, multi-level, collaborative, socialorganisational design for researching health sector accreditation
[LP0560737]. BMC Health Services Research, 6, 113.
CHEN, J., RATHORE, S. S., RADFORD, M. J. & KRUMHOLZ, H. M. (2003)
JCAHO Accreditation And Quality Of Care For Acute Myocardial
Infarction. Health Aff, 22, 243-254.
COLLOPY, B. T. (2000) Clinical indicators in accreditation: an effective
stimulus to improve patient care. International Journal for Quality in
Health Care, 12, 211-216.
DE BRUIJN, H. (2002) Performance measurement in the public sector:
strategies to cope with the risks of performance measurement.
International Journal of Public Sector Management, 15, 578-594.
DE WALCQUE, C., SEUNTJENS, B., VERMEYEN, K., PEETERS, G. &
VINCK, I. (2008) Comparative study of hospital accreditation programs
in Europe. Health Services Research (HSR). KCE reports. Brussels,
Belgian Health Care Knowledge Centre (KCE).
DEVERS, K. J., PHAM, H. H. & LIU, G. (2004) What Is Driving Hospitals'
Patient-Safety Efforts? Health Aff, 23, 103-115.
DICKSON, S. & NICKLIN, W. (2008) The Value and Impact of Accreditation in
Healthcare: A Review of the Literature Accreditation Canada
(http://www.isquaresearch.com/ResearchList.aspx).
EDDY, D. M. (1998) Performance measurement: problems and solutions. Health
Affairs, 17, 7-25.
FOSTER, G. (1994) Fishing with the net for research data. British Journal of
Educational Technology 25 91-97.
GILLHAM, B. (2000) Developing a questionnaire London, Continnum
GIRAUD, A. (2001) Accreditation and the quality movement in France. Quality
and Safety in Health Care, 10 (2), 111-116.
GRASSO, B. C., ROTHSCHILD, J. M., JORDAN, C. W. & JAYARAM, G.
(2005) What is the measure of a safe hospital? Medication errors missed
by risk management, clinical staff, and surveyors. J Psychiatr Pract, 11,
268-73.
GREENFIELD, D. & BRAITHWAITE, J. (2009) Developing the evidence base
for accreditation of healthcare organisations: a call for transparency and
innovation. British Medical Journal, 18, 162.
15

GREENFIELD, D., BRAITHWAITE, J. & PAWSEY, M. (2008) Health care

accreditation surveyor styles typology. Quality Assurance, 21, 435-443.
GREENFIELD, D., PAWSEY, M., NAYLOR, J. & BRAITHWAITE, J. (2009)
Are accreditation surveys reliable? Int J Health Care Qual Assur, 22, 10516.
GRIFFITH, J. R., KNUTZEN, S. R. & ALEXANDER, J. A. (2002) Structural
versus outcomes measures in hospitals: A comparison of Joint
Commission and Medicare outcomes scores in hospitals. Quality
Management in Health Care, 10, 29 - 38.
HEATON, C. (2000) External peer review in Europe: an overview from the
ExPeRT Project. International Journal for Quality in Health Care, 12, 177182.
HEUER, A. J. (2004) Hospital accreditation and patient satisfaction: testing the
relationship. J Healthc Qual, 26, 46-51.
HIROSE, M., IMANAKA, Y., ISHIZAKI, T. & EVANS, E. (2003) How can we
improve the quality of health care in Japan?: Learning form JCQHC
hospital accreditation. Health Policy, 66, 29 - 49.
HOLDFORD, D. (2008) Content analysis methods for conducting research in
social and administrative pharmacy. Res Social Adm Pharm, 4, 173-81.
HURST, K. (1997) The nature and value of small and community hospital
accreditation. International Journal of Health Care Quality Assurance 10,
94-106.
ISQUA (2007a) International accreditation standards for healthcare external
evaluation organizations Third ed., Published by The International
Society for Quality in Health Care
ISQUA (2007b) International principles for healthcare standards: A framework
of requirements for standards. thrid ed., International society for quality
in health care.
JAAFARIPOOYAN, E. (2003) Optimizing the performance of a hospital
evaluation system based on the perceptions and expectations of the
provincial hospitals' directing board (in Farsi). School of Public Health.
Tehran, Tehran University of Medical Science.
JOVANOVIC, B. (2005) Hospital accreditation as method for assessing quality
in healthcare. Oncology, 13 (3), 156-7.
LOEB, J. M. (2004) The current state of performance measurement in health
care International Journal for Quality in Health Care, 16 (1), i5-i9.
LUPTOM, G. & DORAN, J. (2006) Assessing the Impact of Accreditation in
Irish Hospitals through performance measurement systems. Irish Health
Services Accreditation Board & National University of Ireland
MARSHALL, M. (1996) Sampling for qualitative research. Family Practice, 13,
522-526.
MAYS, G. (2004) Can Accreditation Work in Public Health? Lessons from
Other Service Industries. University of Arkansas for Medical Sciences.
MONTAGU, D. (2003) Accreditation and other external quality assessment
systems for healthcare. Review of experience and lessons learned. London,
Department for international development.
NANDRAJ, S., KHOT, A., MENON, S. & BRUGHA, R. (2001) A stakeholder
approach towards hospital accreditation in India. Health Policy and
Planning, 16, 70 - 79.
O'CONNOR, E., FORTUNE, T., DORAN, J. & BOLAND, R. (2007) Involving
consumers in accreditation: the Irish experience. Int J Qual Health Care,
19, 296-300.
16

VRETVEIT, J. (2005) Which Interventions Are Effective for Improving

Patient Safety? A Review of Research Evidence. Stockholm, Medical
Management Centre, Karolinska Institutet.
OVRETVEIT, J., BATE, P., CLEARY, P., CRETIN, S., GUSTAFSON, D.,
MCINNES, K., MCLEOD, H., MOLFENTER, T., PLSEK, P. &
ROBERT, G. (2002) Quality collaboratives: lessons from research. BMJ,
11, 345-351.
POMEY, M.-P., CONTANDRIOPOULOS, A.-P., FRANCOIS, P. &
BERTRAND, D. (2004) Accreditation: a tool for organizational change in
hospitals? International Journal of Health Care Quality Assurance, 17,
113-124.
POMEY, M. P., FRANCOIS, P., CONTANDRIOPOULOS, A. P., TOSH, A. &
BERTRAND, D. (2005) Paradoxes of French accreditation. Quality and
Safety in Health Care, 14, 51-55.
PONGPIRUL, K., SRIRATANABAN, J., ASAVAROENGCHAI, S.,
THAMMATACH-AREE, J. & LAOITTHI, P. (2006) Comparison of
health care professionals' and surveyors' opinions on problems and
obstacles in implementing quality management system in Thailand: a
national survey. International Journal for Quality in Health Care, 18, 346351.
POPE, C. & MAYS, N. (Eds.) (2006) Qualitative research in health care (3ed.),
Oxford, Blackwell Publishing.
ROA, D. V. & ROONEY, A. (1999) Improving health services delivery with
accreditation, licensure, and certification. Quality Assurance Brief, 8
ROONEY, A. & BARNES, K. (2001) Assessing the cost effectiveness of hospital
accreditation in two developing countries. Joint Commission Resources
(JCR) and The Joint Commission, Council for Health Services
Accreditation of South Africa, KwaZulu Natal Province, and Zambian
Central Board of Health, University Research Co., LLC/Center for
Human Services for the Quality Assurance Project, WHO, USAID.
SCRIVENS, E. (1993) An evaluation of the hospital accreditation programme.
Hospital Accreditation Programme. Bristol.
SHAW, C. (2001) External assessment of health care. BMJ, 322, 851-854.
SHAW, C. (2004a) The external assessment of health services. World Hospitals
and Health Services, 40 (1), 24-7.
SHAW, C. D. (2000) External quality mechanisms for health care: summary of
the ExPeRT project on visitatie, accreditation, EFQM and ISO
assessment in European Union countries. International Journal for Quality
in Health Care, 12, 169-175.
SHAW, C. D. (2003) Evaluating accreditation. International Journal for Quality
in Health Care, 15, 455-456.
SHAW, C. D. (2004b) Toolkit for accreditation programs: Some issues in the
design and redesign of external health care assessment and improvement
systems. Australia, International Society for Quality in Health Care.
SHAW, C. D. (2006) Accreditation in European health care. Jt Comm J Qual
Patient Saf, 32 (5), 266-75.
SILVERMAN, D. (2005) Doing qualitative research: A practical handbook, Sage
Publications Inc.
SNYDER, C. & ANDERSON, G. (2005) Do Quality Improvement Organizations
Improve the Quality of Hospital Care for Medicare Beneficiaries? JAMA,
293, 2900-2907.
17

SUNOL, R., NICKLIN, W., BRUNEAU, C. & WHITTAKER, S. (2009)

Promoting research into healthcare accreditation/external evaluation:
advancing an ISQua initiative. International Journal for Quality in Health
Care, 21, 27-28.
WALSHE, K., WALLACE, L., FREEMAN, T., LATHAM, L. & SPURGEON,
P. (2001) The external review of quality improvement in health care
organizations: a qualitative study. Int J Qual Health Care, 13, 367-374.
WHO (2003) Quality and accreditation in health care services: A global review.
Geneva, Department of Health Service Provision.
WILLIAMS, S. C., SCHMALTZ, S. P., MORTON, D. J., KOSS, R. G. & LOEB,
J. M. (2005) Quality of Care in U.S. Hospitals as Reflected by
Standardized Measures, 2002-2004. N Engl J Med, 353, 255-264.

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