The attitudes of hospital directors towards normalising accreditation standards: A qualitative descriptive study for Saudi Arabia

BACKGROUND: Accreditation is an important performance management tool. The engagement of stakeholders in pursuing accreditation plays a critical role in integrating standards into routine practice. OBJECTIVE: This study explores the attitude of hospital directors towards accreditation and investigates the mechanisms of normalising standards in Saudi Arabian hospitals. METHODS: Fifteen hospital directors across Saudi Arabia participated in semi-structured qualitative interviews. The interviews were conducted virtually, audiotaped, transcribed verbatim, and then analysed thematically using the NVivo-12 software package. The normalisation process theory (i.e. coherence, participation, actions and monitoring) was adopted to frame the study and describe the findings on normalising accreditation standards heuristically. RESULTS: Overall, the hospital directors perceived accreditation favourably, particularly by those with more experience or previous exposure to accreditation. This attitude was a factor in normalising standards into daily operations. The clarity of standards, availability of full-time quality professionals and alignment of accreditation standards with hospital strategies assisted hospital directors in making sense of accreditation (coherence) and moving towards engaging hospital teams in the process (cognitive participation). This motivation-driven engagement catalysed the initiation of purposeful operational activities to integrate standards in operations (collective actions). The integration included distributing standard sets to relevant owners, conducting gap analysis, constructing a corrective plan and prioritising tasks within timeframes. Despite the financial and structural constraints experienced, the integration resulted in enhanced organisational safety culture, team spirit, communication, public trust, reporting of safety concerns and standardising of procedures. Following the integration, the objective appraisal of accreditation benefits (reflexive monitoring) was critical in addressing what went wrong, what worked well, and subsequently in sustaining performance gains. CONCLUSION: The effectiveness of integrating accreditation standards heavily relies on making sense of accreditation and understanding the mechanisms through which standards are routinised into operations. This study, using normalisation process theory constructs, indicates that standards integration phases are sequential, interlinked and influenced by culture, teamwork and leadership engagement. The findings helped in clarifying the accreditation operating process which may provide advantages to policymakers and stakeholders in making informed decisions on the implementation of accreditation.