Healthcare: Accreditation and Standards


The comprehensive quality management approaches of Total Quality Management (TQM) and Continuous Quality Improvement (CQI) are rapidly spreading and finding their way into the management of healthcare organizations around the world. Most healthcare managers and policymakers now agree on the need for the evaluation of quality improvement. However, there is no consensus on the quality evaluation approach. Usually, the choice depends on patient needs, the needs of decision-makers in the organization, and other organizational needs.

Healthcare is one of the greatest challenges in the United Arab Emirates (UAE). Every day, there are several media reports on the deterioration of health services and patient complaints from medical errors. This made the politician discuss the declination in UAE health services in the federal council and ask for urgent solutions. The present situation drives the team’s organization to find an approach that would help to evaluate and improve the status quo and raise the level of healthcare services from minimal to optimal.

A team of senior managers was assigned to improve healthcare quality and safety in their current organization. The team’s organization is Acute Care Hospital, which is located in Dubai. It is considered one of the biggest public service providers in the region, licensed by the Dubai Health Authority as mandated by federal law. The facility has 568 beds and it serves a patient population of about 1.9 million.

This paper is a report written by the team of senior management that was assigned to improve healthcare quality in the aforementioned organization. The overall aim of this report is to explore different standardization mechanisms that can be used in evaluating the quality of services in the facility. This is aimed at assisting higher management in their decision to choose the most suitable standardization mechanism for their facility. Additionally, this report will include an overview of the phases involved in accreditation the potential impact they can have on the organization.

Exploring different evaluation mechanisms

An external quality evaluation mechanism is a process that evaluates organizational services against published standards using a peer review team moderated by an independent authority. It was initiated in response to the demand for accountability, access, and transparency in healthcare systems throughout various countries. External evaluation includes different accreditation and certification programs like EFQM and ISO, which are widely used among healthcare organizations worldwide. A standardization organization develops standards and guidelines to ensure and encourage good practice. It has different purposes and different capabilities. However, selecting an evaluation model depends on situational analysis of the current healthcare organization’s needs and expectations.

During accreditation, the organization being accredited voluntarily allows an independent body to evaluate its system and processes and compare the standards set by the independent body. Accreditation standards aim to provide a designed framework to identify priorities. Optimal conditions for performance make up accreditation standards. The conditions are regarded as optimal because the accreditation body has to make sure that it sets standards that can be achieved. They help organizations to improve their processes and systems constantly. An organization is accredited after evaluators coming from outside the organization assess the processes and systems of the organization and confirm their compliance with set standards. This is normally done on a triennial or biennial basis.

Certification and accreditation do not refer to the same thing despite this confusion in corporate circles. In certification, the organization being certified does not necessarily have to be given a certificate by the certifying body. An example of certification is the one done by the International Organization for Standardization (ISO). ISO develops standards and guidelines but business sectors and local bodies authorized by ISO do the bulk of the certification work. The aforementioned sectors and bodies are therefore the ones that audit organizations against ISO standards to check if they meet the standards set by ISO. Conversely, an accreditation organization directly accredits healthcare organizations after the former’s professionals against the specific standards of the accreditation organization audit the latter.

ISO is an international standardization organization that is well recognized and accessible in many countries. It is a non-governmental organization with an international network and therefore it is represented in each country. Organizations have complained that ISO 9001 is costly and time-consuming. This has been attributed to the fact that it focuses on the documentation of management systems as opposed to other models that involve extensive interviews.

Despite these shortfalls as perceived by its users, ISO standards have the advantage of being focused on patient safety, effectiveness, and efficiency of care. In addition to this, ISO standards are generic and optimal. They aim at providing an optimal continuous quality improvement (CQI) framework in healthcare management systems within organizations while focusing on procedures and processes rather than structure and outcome.

One way to meet the challenges that are encountered while creating a high-performance healthcare organization is the approach of the European Foundation for Quality Management (EFQM). EFQM is usually the preferred self-assessment method for a European healthcare organization. The main aim of the EFQM approach in the management of the quality of processes and maintenance of excellence. It advocates for strict evaluation of all organizational activities. It should also be a continuous process aimed at improving organizational performance. Stakeholder demands should be met by the organizational performance.

This philosophy is directly related to TQM. Studies have shown EFQM to be more holistic than its traditional counterparts including JCI. The conceptual framework of EFQM is similar to that of Donabedian’s that differentiates structure, process, and outcome. These qualities of Donabedian’s idea are in line with the EFQM model (Nabitz et al. 2000). The assessment of quality in EFQM is based on its criteria and sub-criteria, and on a measuring instrument called RADAR (Results-Approach-Deploy-Assess-Review). The aforementioned instrument is a modification of the Plan-Do-Check-Act cycle of Deming.

EFQM is a popular model for healthcare organizations in Western Europe. It has a framework that enabled it to compare organizations and have better initiatives for managing quality. However, it is not specific enough to address all areas relevant to healthcare. Despite this, it has been accepted in various organizations due to the aforementioned initiatives for managing quality.

A study was done in European hospitals to identify the systemic differences in quality management between accredited hospitals, ISO-certified hospitals, and those that were neither ISO certified nor accredited. The study showed that accredited hospitals scored 66.9; ISO certified hospitals scored 60 and their unaccredited and non-certified counterparts scored 51.2 concerning quality improvement assessment.

This proves the importance of accreditation in ensuring quality and safety structures in hospitals. However, hospitals may take a decision based on what they aim to achieve from participation in an accreditation or certification program. The decision is also based on what it would cost to get accreditation and what external pressures exist as incentives from regulators, contractors, and patients.

Situational analysis

To assist decision-makers appropriately in choosing the most suitable external evaluation system for their healthcare organization, the team will present recent statistics related to healthcare in the country and their organization. About the UAE, the country of location of the team’s organization, recent reports by The National Fund stated that over 70% of UAE citizens prefer to seek Medicare overseas (Sengupta 2013). This reflects the lack of trust in the local medical system, which costs the country about $2 billion annually (Gornall & Underwood 2009). This situation is unacceptable for a country that wants to establish itself as a hub for global medical tourism.

The Ministry of Health announced in 2009 that a rating system for doctors and hospitals would be introduced as part of a drive to make the country a destination for medical tourism. In addition, DHA announced that it is going to publish performance ratings for UAE hospitals and clinics based on admission data, inspection reports, customer surveys, and success rates (Underwood 2008). This step was meant to increase transparency and competition within the healthcare sector in the UAE. According to DHA, the number of complaints in 2012 doubled, as compared to 2010 (Hassani 2012). The majority of these complaints pointed to medical errors that arise from medical malpractice, lack of proper communication, and lack of good documentation.

The organization being studied by the team delivers comprehensive healthcare services. However, recent statistics reflect an increase in the rate of incidences occurring in the past three years. Medical errors and lack of adequate staff training have contributed to 55% of the incidents (Rooney & Ostenberg 1999). This reflects the need to set and maintain evidence-based standards and ensure adherence to those standards regularly.

Additionally, there is a need for a clear, uniform training strategy throughout the organization aimed at enhancing the performance of employees. Studies have proven that organizations that implement staff training programs are more likely to retain their healthcare professionals, improve the culture of the organization and mitigate the losses that occur due to malpractice (Shaw 2000).

Reasons for accreditation

Based on the above situational analysis and the expectations of the stakeholders of the organization being studied by the team, members decided that accreditation is the most effective evaluation system for the organization. The decision is supported by the organization’s need to seek an external evaluation model to increase accountability. Although the decision to seek accreditation is voluntary, it is connected to the desire to maintain good standards, achieve patient satisfaction, and meet market and legal demands.

Despite the cost, stress, and time-consuming nature of accreditation, it is effective in encouraging adherence to professional norms and standards (best practices) in healthcare. Studies have shown that healthcare organizations that participate in accreditation have demonstrated a strong commitment toward improving the quality of their services in addition to advanced risk management (Ullah et al. 2012). Furthermore, Accreditation stimulates and improves the integration and management of health services. Studies have shown that organizations that adopt optimum accreditation respond more effectively to outbreaks and novel healthcare-related issues (Davis et al. 2012).

For instance, during the H1N1 outbreak, accredited organizations demonstrated effective response and control of the disease because they had response plans in place. Additionally, accreditation establishes a comparative database of healthcare organizations. Accreditation can be used to ensure accountability in healthcare organizations. It can also help an organization to have a good rating, and strengthen the confidence of the public in local healthcare. This leads to better healthcare that can attract medical tourists. Accreditation also reduces healthcare costs by focusing on increased efficiency and effectiveness of services (Wever et al. 2011).

It improves patient satisfaction and ensures that patients prefer the hospitals that have it over those that do not. Additionally, it attracts high-quality professionals and foreign patients and improves medical tourism. This means that the widespread application of accreditation in medical organizations within a given country can potentially make the country a hub for medical tourism.

The strategic plan 2015 for the Dubai Health Authority encourages international accreditation. Accreditation enables healthcare organizations to go through continuous cycles of improvement as they prepare themselves for accreditation. The organizations improve their structure, processes delivery systems, clinical outcomes, and professional conduct. With accreditation, an organization can show an image of professionalism and patient safety to the public. Research has revealed that customer satisfaction is usually higher in accredited healthcare organizations as compared to their counterparts that are not accredited (Why invest in healthcare in Dubai? 2010).

Accreditation is therefore important in the context of UAE because it gives the locals confidence in the local healthcare system. In addition, accreditation leads to better teamwork and sharing of information between healthcare professionals. Research has established that 70% of all medical errors can be avoided if there was more coordination between different medical teams (Saitz 2010).

Different accreditation systems

Different countries and regions have developed several accreditation systems. The World Health Organization (WHO) recommended several systems of accreditation like JCAHAO/JCI from the United States, CCHSA Canadian System, the ACHS Australian System, the ANAES system of France, the QHNZ system of New Zealand, and the UK based system.

Although most accreditation bodies have similar philosophies, frameworks, and principles, some variations exist between them. For example, the ACHS Australian System standard, which was written by doctors, was found to have the greatest focus on clinical activities and evaluation rather than improvement of patient outcomes. In contrast, multidisciplinary teams wrote JCI and Canadian systems standards and they focus on inspecting and judging the Plan-Do-Study-Act and Structure-Process-Outcome. The main objective of the CCHSA is to ensure that the safety and quality of healthcare are such that it is reassuring to members of the public.

JCI is considered to have a better record in terms of its focus on quality and safety improvement as compared to other accreditation systems. It is a reliable system of accreditation. This can be proven by the fact that almost 91% of all research papers recommend the JCI accreditation system. Therefore, the JCI system of accreditation is exceptionally good and it is designed for implementation in diverse cultural environments.

Only the CCHSA system of Canada comes close to JCI on these attributes. None of the other accreditation systems has developed a database of healthcare providers and none of them has branches all around the world like JCI. Only JCI has developed a database of all accredited organizations. It also makes organizational comparisons. Additionally, only JCI has international branches that make it reach out to a vast geographical area.

Reasons for choosing JCI accreditation

The team decided to adopt JCI as the accreditation system for their organization. Apart from being the oldest and the most prominent accreditation body in the world, JCI is implemented by the healthcare organizations under the Ministry of Health in the UAE. Furthermore, over fourteen hospitals are already accredited with JCI in the UAE (Auras & Geraedts 2010). Therefore, implementation of JCI accreditation in the team’s organization will give the organization a competitive edge and make it utilize the aforementioned benchmarking opportunities.

JCI standards have a strong focus on quality and safety. It uses many quality indicators and focuses on clinical outcomes. JCI also encourages stakeholders to have better strategies for information sharing and have better coordination mechanisms (Shammaa 2008). This is quite useful because the majority of medical errors happen due to lack of information sharing, lack of cooperation, and lack of communication between healthcare stakeholders.

The JCI accreditation program improves the quality of patient care and improves the safety of patients (Agrizzi & Aghighi 2011). This has an overall effect of giving the general public confidence in the local healthcare system. Research has shown that JCI accredited organizations have more public confidence than those that are accredited by other accrediting bodies. This is because JCI is focused on quality as well as accountability and because JCI promotes the rights of patients. Additionally, public confidence in JCI accredited organizations can be attributed to the fact that the JCI accreditation system promotes an ethical work culture (Greenfield & Braithwaite 2008).

Furthermore, JCI keeps a database and thus it can compare accredited organizations, enabling benchmarking with regional and international healthcare organizations (Ramanna 2006). Finally, the JCI system helps build a good reputation of the organization and attract high-quality professionals and foreign patients (Arce 1998). Therefore, the JCI choice is good for the motivation of staff members of the organization. The staff will be motivated and thus they will be productively engaged in accreditation activities.

Appendix A: Comparison of Different Accreditation Systems
Comparison of Different Accreditation Systems

Accreditation phases

Organizations that decide to be accredited are expected to go through a couple of steps before they become accredited. During each phase, different activities and changes are likely to take place in the organization, especially on the level of organizational structure and processes. A comprehensive accreditation plan followed by the involvement and commitment of every individual in the organization is the key element of a successful scheme of accreditation (Agrizzi & Aghighi 2011). Generally, accreditation is undertaken in three main phases. These include the pre-accreditation phase, the accreditation phase, and the post-accreditation phase. Concerning the proposed accreditation standards (JCI), the team has analyzed the process of JCI accreditation in the context of the team’s organization.

The pre-accreditation phase

The pre-accreditation phase is characterized by several improvement projects that shift the paradigm within the organization. In this phase, a detailed accreditation plan with known responsibilities and timeframes is designed. The plan includes the investment of resources in implementing the standards and self-assessment to determine the level of alignment with the JCI standards. The team would suggest establishing different committees to address each JCI standard, which tackle all required elements about implementing the standard and ensure that members of staff in the organization are adequately trained on all aspects of self-assessment.

Studies have suggested that self-assessment is a vital tool for improving the quality of services. It is also considered an essential element for continuous quality improvement. It allows commenting on different processes and policies within the system about the given standards and helps the organization to realize change and improvement.

Among the challenges the team expects in the pre-accreditation phase is staff resistance to change. Staff resistance arises from stress associated with self-assessment and consideration of the possible consequences of accreditation. It also arises from the emerging requirements of accreditation. Such requirements include the increased need for documentation, which is considered unpleasant especially for healthcare workers who would prefer to spend the majority of their time with patients. Additionally, following specific guidelines in practice might create a sense of loss of autonomy for experienced healthcare professionals.

Nevertheless, involving and guiding healthcare professionals and governing their practice are the greatest benefits of the mentioned period. These benefits lead to the acceptance and compliance of healthcare workers to the accreditation process. The pre-accreditation phase is expected to last for a period ranging from 12 to 24 months.

The accreditation phase

In this phase, the organization is supposed to go through the external peer assessment of the accrediting body to assess their compliance with set standards. This phase includes tracing the organization’s staff and patients. The organization aims to seek an accreditation award in addition to a report, which includes a list of findings and recommendations for improvement. Organizations that have significant gaps are likely to fail the accreditation survey. However, areas that can be improved are highlighted during the external assessment of their systems and processes.

Among the challenges the team expects in this phase is the general stress of evaluation that the whole organization passes through. However, the result of the accreditation survey depends on the efforts put in the pre-accreditation phase, as the external reviewers will validate the self-assessment done in that phase.

The post accreditation phase

After attaining accreditation, the organization is expected to continue with quality improvement. All the committees continue operating and working on the findings identified by JCI surveyors along with self-assessments and quality improvement projects. The liaison with JCI will continue through continuous updates on new studies related to healthcare.

The challenge that the team expects in this phase is the loss of motivation in staff members. This is because after completing accreditation, staff members are exhausted and they desire to disassociate themselves with accreditation-related issues. However, peer review by JCI and continuous self-assessment during the preparation period will give a base for continuous quality improvement of processes and systems in the organization.


Various evaluation models have been reviewed in this paper and a decision has been made on the most appropriate model. The review looked at situational analysis and recent statistics of the current organization, and its country of location. The paper recommends accreditation (particularly JCI) as the best external evaluation body for the current organization. This accreditation will help the organization in overcoming internal quality defects and market pressures. It will also give the organization a competitive advantage and help it benchmark with other accredited local organizations. Finally, accreditation phases and their impact on the organization were discussed and their respective challenges analyzed.

Reference List

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