Background
Hospital accreditation programmes are avenues through which a complex policy intervention functions to promote adherence to quality and safety management standards and drive continuous quality improvement. On a more practical level, these programmes represent a quality management system (QMS), total quality management (TQM) or continuous quality improvement (CQI) standards that should lead to an improvement of the hospital’s overall performance [
1‐
3]. While accreditation has been widely adopted in healthcare organizations, the history of quality management theory and accreditation was initiated in manufacture industries with different organizational culture and environment [
4,
5], that are the two important determinants for the adoption of QMS implementation [
6,
7]. Knowledge gaps, therefore, remain existing and raise questions about whether the adopted theory, standards, and practices outside the health care industries will fit in and whether it has an impact on the overall health care organization performance as well as on patient satisfaction [
8‐
10].
A quality management system is the key important link between hospital accreditation and the end point of quality and safety. Hence, previous studies have identified certain organisational factors needed for successful adoption of QMS standards such as strong leadership, continuous quality improvement, and human resource development [
6,
7]. Studies of these factors have also identified that internal organisational factors (size, ownership, culture, leadership, and technical capability) and of environmental factors (health system and market competition intensity) play as driving forces for QMS implementation as well as hospital accreditation [
6,
11,
12].
Aside from hospital characteristics, healthcare market competition is one of the external factors that drive hospital quality. Previous studies found that in a highly competitive market, hospitals face more pressure for quality improvement efforts [
13,
14]. In such an environment, the hospital accreditation status adds a competitive advantage since it is viewed as a hospital quality indicator that is considered by patients, referral doctors, and other purchasers [
15‐
17]. In Indonesia, hospital accreditation status is required as a credential indicator by the national health insurance agency [
18]. Furthermore, the sustainability of healthcare accreditation highly depends on government support, market size, funding, and continuous evaluation of the accreditation programme and standards [
6,
19‐
21].
The implementation of hospital accreditation in Indonesia as a mechanism of external quality assurance was initiated and has been ongoing since 1995. The programme is managed by the Indonesia Commission on Accreditation of Hospitals (ICAH) as a formal government agency for hospital accreditation, which later became a more independent agency. The earlier Indonesian hospital accreditation standard entailed of three different schemes, based on the number of service unit/department evaluated during the survey, i.e. basic (5 service unit), advance (12 service unit), and full accreditation (16 service unit) [
22]. Started in 2013, the Joint Commission International (JCI) hospital accreditation standard that focused more on the process of care with patient safety as the ultimate goal and considered hospitals as an integrated system was adopted. Thus hospitals could not be evaluated as separated services [
18,
22].
Intended as a safeguarding mechanism, policies which were started after mandatory policy for hospital accreditation under the Indonesian Hospital Act (2009) have intensified the external pressure for hospitals [
23]. The urge to implement the international standards adopted from (JCI) which began in 2013 added more pressure for hospitals to apply for accreditation [
24]. Moreover, considering that removing physical and financial barriers to health care facilities will not guarantee the outcome when it is provided in substandard care [
25,
26], accreditation also required as a credentialing mechanism for healthcare providers under universal health care quality coverage policy [
22,
24].
As the basic intention of accreditation is to improve hospital quality performance, several studies have been carried out to evaluate its benefit. Systematic reviews of the health sector accreditation’s impact have identified two areas that consistently benefit from the accreditation: promoted organisational change and professional development [
8,
10,
27,
28]. These studies have found that the association between accreditation and organisational performance, financial indicator, quality measures, and programme assessment was inconsistent, and the correlation with patient satisfaction was not sufficiently conclusive [
9,
10,
16,
27,
28]. Hinchcliff et al. concluded that based on a limited amount of evidence, a potential correlation existed between accreditation and high-quality organisational process as well as clinical care [
28].
Changes in hospital performance can be approached based on the quality dimension. The World Health Organisation (WHO) and the Institute of Medicine (IOM) suggested the following quality dimensions to describe hospital performance: accessibility, efficiency, effectivity, acceptability (patient-centred), equity, and safety [
29]. At the hospital level, bed occupancy rate (BOR), turn over interval (TOI) and average length of stay (ALOS) are widely used to describe the hospital capacity, its utilisation efficiency. These indicators also indirectly represent accessibility [
23,
30], and, at the health system level, are also used to measure the system’s capacity to serve and provide access to care. In addition, the gross mortality rate (GMR) and net mortality rate (NMR) are widely reported as the hospital-based indicators that describe overall patient outcome and clinical effectiveness [
29,
31].
Studies of the effect of hospital accreditation are still characterised by a lack of strong and consistent evidence regarding the benefit of accreditation on clinical performance in particular [
8,
10,
28,
32]. In addition, most of those studies, which have been performed in developed countries, are calling for studies in developing countries. A qualitative report of hospital accreditation programmes in low and middle-income countries has identified a need to describe hospital accreditation standard elements both in terms of successful implementation and its relation with hospital performance [
19,
20,
33].
As the fourth most populous country in the world, Indonesia faces a serious population maldistribution resulted in wide socio-economic disparities. Almost 70% percent of its inhabitants are condensed in one island, Java, which is only equal to 11,5% of Indonesia land area, while the rest are sparsely distributed in others 17.000 islands [
34]. Under decentralized health system policy, each province and district have financial and operational authority. Most of the responsibilities regarding health care were transferred to the district level while the provincial government is only responsible for the coordination of referral care between districts [
35]. While decentralization is intended to reduce disparities and develop local capabilities, the latest studies found that the disparities remain exist make it not easy to be treated equally [
36,
37]. Hence, in a country with extreme diversity such as Indonesia, studying health system at the national level needs to be very carefully performed [
38,
39]. Bearing in mind these circumstances, our study is intended as a starting point for further research to have a better understanding of health system at the national level. For that reason, we selected East Java, a province with 38 districts and 39.3 million inhabitants (16% of Indonesian) that has more similar characteristics with other provinces outside Java [
34,
40]. Furthermore, compared to other provinces, East Java has fairly balance development in term of income distribution and regional equity [
40].
This study explores the association between organisational design factors and market competition intensity with the hospital accreditation status. We further examine the difference in hospital performance indicators across their accreditation status. The findings from this study will provide supporting evidence towards understanding the link between organisational design, accreditation status and hospital performance in developing countries.
Discussion
We investigated factors associated with hospital accreditation status, i.e., organizational design factors (size, ownership, specialty, and the number of specialist physicians) and market competition intensity as the drivers for hospital accreditation in East Java Indonesia. We also compared the differences in hospital performance indicators between the accreditation status.
Our findings show that hospital size and ownership are significantly associated with a higher likelihood of a hospital being accredited, while the hospital specialty types, the number of specialists, and market competition intention do not significantly relate to the accreditation status. Although not statistically significant, accredited hospitals tend to have a higher BOR and ALOS, though this is concurrent with a higher mortality ratio.
The role of organisational design factors and market competition intensity in determining hospital accreditation status
We found that in our studied province, East Java, large, government-owned, and general hospitals have a higher probability of being accredited. Previous reviews have identified that, unlike small hospitals, large hospitals have more resource capacity; however, they also tend to have a hierarchical culture and more bureaucracy, which are a hindrance to the egalitarian culture needed to implement quality management and safety standards [
28]. Organisational design factors such as size, ownership, and specialty describe the hospital’s capacity to serve the catchment area. They also simultaneously represent the organisation’s structure and culture and function as important determinants of the implementation of accreditation standards [
6,
28]. The scarcity of resources, finances, and staff adequacy are defined as the capacity barriers faced by small hospitals, such as rural hospitals or hospitals in less developed countries, when implementing hospital accreditation standards [
19,
20,
33]. Our findings emphasise the role that government support should play as the facilitating factor for overcoming the financial and resources barriers faced by hospitals while implementing the fundamental structure for continuous quality improvement [
45,
46].
In terms of ownership, we also found that, compared with other government hospitals, military-managed hospitals have a higher probability of being accredited. The characteristic and structure of the owner is highly influenced by a hospital’s structure and organisational culture, which are important determinants of successful quality improvement strategies [
6,
28]. While government hospitals tend to have more support and resources, they also exhibit a highly bureaucratic quality that hinders continuous improvement [
6,
47]. The command structure in military-managed hospitals can be a hindrance to a culture of continuous quality improvement, but it can also act as a catalyst when innovation is diffused from the top down [
6,
48]. Other studies related to ownership and hospital quality mostly divide ownership into ‘for profit’ and ‘not-for-profit’ and associate this trend with the organisation’s competitive behaviour [
49]. The ownership characteristics of Indonesian hospitals are not strictly associated with for-profit behaviour. Mixed ownership characteristics might influence their relationship with quality improvement strategies and needs further investigation.
Furthermore, we found the number of specialist physicians was not related to the hospital’s accreditation status even though the number was slightly higher in accredited hospitals. Hospital accreditation standards require an adequate human resource capacity to be present for the structure or input standards of continuous quality improvement to be actualised. Most of the studies of hospital accreditation investigate the role or involvement of physicians, but not their actual number [
27,
28,
50]. Those studies are performed in developed countries where the number of human resources is not a real problem, while in most developing countries the scarcity of human resources remains a huge problem [
51]. Other studies in low and middle-income countries support the evidence that scarcity of finances and human resources remains the fundamental barrier at the structural level for having an effective hospital accreditation programme [
45,
46].
We also found that market competition intensity has no significant associated with hospital accreditation status. A study of the impact of hospital competition on the inpatient quality indicators concluded that market competition had a positive unidirectional impact on the multidimensional nature of quality, especially in terms of visible aspects for the patient such as physician skill and expertise [
17]. Other less visible indicators such as hospital structure and management, which mostly are measured as determinants for accreditation standard, were not found [
17,
52]. In addition, the implementation of a universal health coverage in 2014 in Indonesia added additional pressure to pursue accreditation status, since accreditation was required by the health insurance provider as a measure for quality assurance. This finding supports previous evidence that a change in the accreditation policy has a significant impact on altering the balance and direction of hospitals’ market competition [
11,
44,
53].
The association between accreditation and hospital performance
Finally, we found no significant differences in hospital performance measures (utilisation or the mortality ratio) across accreditation status, though mortality rates were slightly higher in the accredited hospitals. These findings are in line with previous reviews showing inconsistent evidence between hospital accreditation, organisational performance, and patient outcomes [
10,
27,
28,
54]. The DUQUE project concluded there was a consistent positive impact of accreditation on the process of care. However, though the benefit of accreditation on clinical outcome improvement is promising, the evidence is not consistent across studies [
32]. The reason behind the higher mortality rate in accredited hospitals may be related to the fact that most referral hospitals are accredited. Compared with non-accredited hospitals, accredited hospitals are mostly large and government-owned and act as referral hospitals which have a greater share of severely ill patients. This pattern may lead to higher mortality and worse patient outcomes.
Strengths and limitations
Many other studies evaluating the factors associated with hospital accreditation status have been conducted in developed countries with established health services and financial systems [
8,
10,
27,
28,
54]. Within its limitation, this is the first study that evaluates the factors associated with hospitals accreditation status as well as its association with hospital performance indicators in one of the provinces in Indonesia, a developing country, and therefore adds evidence regarding the adoption and potential benefit of accreditation when resources are limited.
The limitation of using secondary data analysis such as problem with data completeness, though it could be managed using appropriate missing data analysis and imputation method, still call the need to improve hospital reported compliance by providing feedback and relating the report with positive consequences. Furthermore, using multiple imputation method will increase the opportunity of conducting a regular and continuous evaluation based on the available secondary data. In addition, the use of the net and gross mortality rates must be interpreted with considerable caution. There are many other factors beyond those that have been collected in this study that may explain differences or the lack of difference in these measures between accredited and unaccredited hospitals, such as the severity of the disease and patient age, which are strongly influenced by hospital classification and service type [
31,
55]. Adjacent to that, the number of hospitals that had completed their performance data was considerably low that influence its representativeness. Hospitals with completed performance data mostly are accredited and have a higher size that could influence their performance.
Baseline data for accreditation status ultimately rely on interpretative data. However, data that form the basis of the accumulative score of hospital achievement in all accreditation standards do not consider the differences of specific successes and failures that occur during the fulfillment of each standard [
55,
56]. Another problem arises from the limitations surrounding accreditation as a measure of the actual QMS implementation that will lead to quality improvement [
57]. The accreditation evaluation was founded on short-term observation that was mainly based on the documented evidence. Since there is no cohort evaluation before and after the application for accreditation, the possibility exists that the accredited hospitals may discontinue the implementation after accreditation [
56].
Strictly speaking, because we surveyed one province of Indonesia, our findings are not necessarily valid for other provinces. However, since East Java is one of the provinces in Java-Bali islands, the main capital area, that has a more comparable socio-economic profile with the other provinces outside Java-Bali [
36], our finding may be potentially useful to other Indonesian provinces. As health care systems are nationally organised, it is difficult to extend similar observations to other low and middle income cuntries (LMICs) in South East Asia. Still, our results may tentatively provide some insights into other LMICs in South East Asia that mostly undergo a health system transformation through a decentralisation strategy and use hospital accreditation as a quality regulation tool [
26,
58].
Recommendation
Our finding that being a large, government-owned hospital is significantly associated with a higher likelihood of being accredited indicates a stronger role for government as a driver for accreditation. However, with the increasing role of private health care, a government takeover of ownership is not a realistic option. The government should mainly oversee either the process of quality assurance or the reporting mechanisms for both public and private health care. Hospital benchmarking should be based on standardised performance reports that are linked to a hospital’s credentialing mechanism [
59,
60]. Such a system will strengthen the accountability of health care.
Small hospitals must get support for basic requirements such as human resources [
45,
46]. A new regulation is necessary to better distribute human resources with supporting facilities and technology. The regulation should also consider non-government owned hospitals, which exemplify most small hospitals. With their limited capacity and the pressure from compulsory accreditation and single-payer insurance policy, a merger could be the only realistic option for small hospitals to cope with when unable to meet the required standard. In addition to overcoming structural barriers, the accreditation process and policies should also be improved. By shifting the emphasis away from administrative compliance, a culture of continuous quality improvement should be encouraged, which is a necessity for a better and sustained hospital performance [
61,
62]. This policy approach will maintain the long-term benefit by making the achievement of accreditation status a result rather than a primary aim in and of itself [
3].
Based on the current regulation, public reporting of hospital performance indicators is mandatory for all hospitals and is required for applying for or renewing the hospital accreditation status. For private hospitals, it is also a pre-requisite for hospital operational relicensing. Even given this rather strong punitive requirement, the compliance still does not meet expectations which reflected in the small number of hospitals with completed performance indicators. One of the mentioned reasons is a lack of reporting ‘meaningfulness’ for the hospital [
63]. Compliance should be viewed as more than a merely administrative requirement [
64]. Meaningful and regular feedback for hospitals based on the reported indicator is important to support reporting compliance and data quality for continuous evaluation [
64]. The limited evidence on the actual impact of accreditation on hospital performance calls for more rigorous research and long-term evaluation while simultaneously providing a window for continuous monitoring and evaluation.
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