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 Table of Contents  
Year : 2021  |  Volume : 65  |  Issue : 2  |  Page : 110-115  

Impact assessment of accreditation in primary and secondary public health-care institutions in Kerala, India

Assistant Professor, Department of Travel and Tourism Management, Govinda Pai Memorial Government College, Kasaragod, Kerala, India

Date of Submission06-Jul-2020
Date of Decision18-Feb-2021
Date of Acceptance04-May-2021
Date of Web Publication14-Jun-2021

Correspondence Address:
Sindhu Joseph
Department of Travel and Tourism Management, Govinda Pai Memorial Government College, Manjeshwar, Kasaragod - 671 323, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_827_20

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Background: Accreditation has become a benchmark for health-care organizations that require huge investment and effort. The impact of accreditation in health-care delivery needs to be assessed. Objectives: The study aimed to assess the impact of accreditation on the quality of public healthcare delivery in primary and secondary healthcare settings in Kerala. Methods: This cross-sectional study was conducted from July 2017 to July 2018 among 621 in-patients in medical wards at accredited (312) and nonaccredited (309) primary (community health center) and secondary (general, women and children, and taluk level hospitals) public health-care facilities. Ten constructs such as physical facility, admission services, patient centeredness, accessibility of medical care, financial matters, professionalism, staff services, medical quality, diagnostic services, and patient satisfaction were used in the study. Nonaccredited and accredited hospitals were compared using Median and Kruskal–Wallis test using SPSS version 22, with a set significance level of P ≤0 .05. Results: The median score of constructs of accredited primary health-care facilities in the Structure, Process, and Outcome domains are higher than the nonaccredited hospitals. There are significant differences between the scores of these three domains in accredited and nonaccredited primary health-care institutions but absent in secondary care institutions. Conclusion: If accreditation has to bring the embedded quality, structural, and procedural aspects of health-care facilities must be improved. Structural upgradation of a health-care facility alone cannot guarantee patient satisfaction. Accreditation process must be perceived as a tool for holistic and continuous transformation of a health-care facility overarching infrastructural and interpersonal domains.

Keywords: Accreditation, patient satisfaction, primary and secondary care, quality health-care delivery, structure-process-outcome model

How to cite this article:
Joseph S. Impact assessment of accreditation in primary and secondary public health-care institutions in Kerala, India. Indian J Public Health 2021;65:110-5

How to cite this URL:
Joseph S. Impact assessment of accreditation in primary and secondary public health-care institutions in Kerala, India. Indian J Public Health [serial online] 2021 [cited 2023 Mar 26];65:110-5. Available from:

   Introduction Top

Quality of health care has been a widely discussed domain, and many institutions and organizations perceive accreditation as a valuable tool for quality transformation. Accreditation had its early beginnings in the USA, where Earnest Codman introduced the “end result system” in 1910, insisting hospitals track each patient to test the effectiveness of health-care delivery.[1] Globally, health-care quality improvement activities are progressing through health-care accreditation programs and accrediting organizations. Accreditation is a means of publicly recognizing a health-care organization against predetermined performance standards of operation by trained external peer reviewers.[2],[3] It enables organizations to have an introspection based on the reports and recommendations of the accreditation team, and therefore, enables them to benchmark themselves.[4]

Accreditation benefits all health-care stakeholders, such as medical and paramedical professionals, patients, and the public as a whole[5] and increases public recognition and trust between users and service providers.[2],[3] Standardization of cost and quality is not enforced in the present health-care system, and therefore, accreditation is the only possible means of proclaiming health-care reliability and authenticity.

Accreditation programs are implemented at international (Joint Commission International), national (for instance, National Accreditation Board for Hospitals and Health-care Providers (NABH-India) and state levels (for example, Kerala Accreditation Standards for Hospitals - KASH). In India, to accredit hospitals at the national level, NABH is set up with full functional autonomy in its operation and working at par with global benchmarks and is being supported by all stakeholders, including industry, consumers, and government. Kerala has the largest number of NABH accredited hospitals in India under the public sector.[5]

It is essential to advance the knowledge on accreditation impact in hospital settings, especially on the infrastructural, procedural, and satisfaction levels, when considering the financial investment, effort, and time to attain quality assurance certifications. Accreditation and quality enhancements and thereby patient satisfaction (PS) is correlated positively by many researchers.[6],[7],[8] Ghareeb et al.[9] found that many countries such as the USA, Australia, Canada, the UK, New Zealand, Jordan, Saudi Arabia, Lebanon, Qatar, and Egypt had well-developed and high-quality primary care accreditation models. Further, Al Tehewy et al.[6] and Williams et al.[10] demonstrated a positive effect of accreditation in their comparative studies at accredited and nonaccredited settings. Nonetheless, many other studies gave contradictory results on the accreditation impact,[11],[12],[13] and few studies focused on the perception of personnel at different capacities in accredited hospitals (for instance, nurses) and various accredited facilities (for example, ambulatory services).[14] Al Otaibi et al.[15] found the reverse effect of accreditation on patient safety and its failure to create total quality management.

Considering the previous studies and their inconsistent results, there is a need to assess the overall effectiveness of accreditation on quality. Further, there is a dearth of studies assessing the impact of accreditation while having a comparison group and from patients' perspective. Most importantly, the impact of accreditation programs in secondary health-care settings lacks evidence in the literature. Against this backdrop, this study aimed to fill these gaps by assessing the impact of accreditation in primary and secondary public health-care settings in Kerala while having a comparison group and from the patients' perspective. The study results will have implications at the policy level and service provider level to restructure the implementation process of accreditation.

   Materials and Methods Top

This study was conducted from July 2017 to July 2018 using a survey questionnaire. The study utilized a positivist paradigm as it measured the impact of accreditation by comparing the quantitative variables before and after the accreditation process and is cross-sectional.

The study approaches the patients as a physical entity that can be measured and controlled with objectivity, neutrality, generalizability, determinism, quantification, and reliability to find out the reality. The indicators used in the study are measurable, and there are similar studies that are positivist in nature.[3],[7],[9],[16] The study used deductive reasoning as a conceptual framework underpinning the research design which was predetermined to extract specific propositions from the general accounts of reality.[17]

The study was planned to compare the two types of hospital settings (accredited and nonaccredited) to understand accreditation impact. Kerala health-care system functions on a three-tier health-care system wherein primary and secondary care facilities serve as an asylum for the rural population. District Hospitals (DHs), General Hospitals (GHs), Women and Children (W and C) hospitals, and the Taluk Head Quarters/Taluk Hospitals (THQHs/THs) provide secondary care.[18] The Community Health Centers (CHCs) represent the primary care hospitals along with Primary Health Centers (PHCs).[18] Hence, the research used stratified random sampling where four strata, GHs, W and C hospitals, THs/THQHs (Secondary Healthcare Facilities) and CHCs (Primary Healthcare Facilities).

Samples were selected randomly from the Thiruvananthapuram region representing Southern Kerala, Ernakulum region representing Central Kerala and Kozhikode region representing Northern Kerala. Participants of the study were in-patients admitted to medical wards at public hospitals, aged 16 years or older, and could speak Malayalam or English language. Being primary care facilities, PHCs were excluded from the study because of the lack of an adequate number of in-patients. To get an authentic number of samples, 10% of the number of beds available from each stratum was included in the study except GHs (15%), where there was only one accredited GH in Kerala [Table 1]. A total of 760 questionnaires were distributed in the Inpatient wards, of which 621 (82%) were valid for the analysis (312 from accredited and 309 from nonaccredited).
Table 1: Selection of subjects (in-patients) from accredited and nonaccredited facilities of different categories

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The questionnaire included 60 items in two sections. The first section sought demographic information on age, gender, educational level, marital status, employment status, and the reason for hospital selection. The second section measured patient's views on health-care delivery on a 5-point scale (1 = strongly agree to 5 = strongly disagree) using ten constructs adapting previous critical studies and models in the area.[19],[20],[21],[22] They are Physical Facility(PF-14items), Admission Services(AS-2 items), Patient Centeredness(PC-7 items), Accessibility of Medical Care(AM-5 items),, Financial Matters(FM-5 items), Professionalism(P-4 items,) Staff Services(SS-4 items), Medical Quality (MQ-4 items), Diagnostic Services(DS-2 items) and Patient Satisfaction( PS-5 items). The five dimensions of the SERVQUAL model (Tangibility, Reliability, Responsiveness, Assurance, and Empathy)[23] and Structure-Process-Outcome (SPO) model of Donabedian[22] are imbibed in the chosen constructs. The overarching constructs were subdivided into structural, procedural, and outcome dimensions according to the Donabedian model,[22] which states that quality enhancement in structural and procedural aspects consequently results in PS (outcome). In this study, structure includes (the context in which care is delivered) infrastructure, medicine availability, staff, financial factors and equipment; process includes (the transactions between patients and health-care providers) patient-centeredness and relationship dimensions; and outcome includes (the effect of healthcare) PS.[22],[23]

The questionnaire was initially developed in the English language and subsequently translated into Malayalam. Based on the result from the pilot test, few questions were omitted from the questionnaire, in which respondents generally did not respond. The validity of the questionnaire was evaluated based on content validity and experts' opinion. Cronbach's Alpha value was higher than the guideline value of IBM SPSS Statistics version 22 (IBM Corp., New York, USA) was used for the data analysis. As the variables under different constructs have been measured in the Likert scale, the averages have been presented using the median value. Statistical significance is calculated by using Kruskal–Wallis test because the data were not normally distributed, the variables being tested was measured in ordinal scale, the observations from both groups were independent of one another and the distribution of the variable in each group was similar. This test is conducted to assess for significant differences on continuous dependent variables (10 constructs overarching SPO domains) by a categorical independent variable (with two groups – accredited and nonaccredited hospitals). Hence, a hypothesis postulates that there is no difference between the construct scores of nonaccredited and accredited hospitals is formulated. Then: H0: Accreditation has not impacted primary and secondary public health-care institutions in Kerala. H1: Accreditation has impacted primary and secondary public health-care institutions in Kerala.

The Institutional Ethics Committee of the parent institution approved the present study. (Order No. B1/RP- ICSSR-02/dated 22/02/2018) and the Health and Family Department, Government of Kerala (Email dated 20/04/2018). Further, details, including the research objectives, and the type of data required, were submitted to ethical review committees of the health-care institutions under the study to review scientific merit and ethical acceptability and subsequently obtained their approval before collecting data. Informed consent was obtained from every participant before the start of the study.

   Results Top

The average score for constructs overarching structural, procedural, and outcome domains for accredited and nonaccredited hospitals have been measured in median.

As shown in [Table 2], the median value of all constructs in primary health-care facilities are higher in accredited hospitals than the nonaccredited. However, in accredited secondary care facilities, most of the constructs show a lower or equal median value than the nonaccredited.
Table 2: Median score for various constructs at accredited and nonaccredited facilities of different categories

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[Table 3] shows that, for constructs overarching structure domain, there are statistically significant differences in scores between nonaccredited and accredited primary health-care institutions, which is found absent in secondary health-care institutions. Hence, it can be assumed that accreditation has caused the structural improvements of primary health-care institutions only.
Table 3: Comparison of Structure and Outcome Domains at different categories of facilities by Kruskal-Wallis test

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[Table 3] also shows that a significant difference in scores for outcome domain (PS) is found between accredited and nonaccredited primary hospitals (χ2(1) = 16.496, P = 0.000 with a mean rank of 42.33 for nonaccredited and 88.67 for accredited). Contrastingly, no significant difference in scores is found between accredited and nonaccredited secondary hospitals (THQH/THQ (χ2(1)= 0.018, P = 0.892 with a mean rank of 85.50 for nonaccredited and 84.08 for accredited and GH (χ2(1) = 0.303, P = 0.582 with a mean rank of 107.24 for nonaccredited and 102.70 for accredited) even though there is a statistically significant difference in scores for W and C hospitals (χ2(1)= 10.962, P = 0.001 with a mean rank of 67.10 for nonaccredited and 46.97 for accredited). Considering the overall scores, it can be assumed that accreditation has impacted in PS only in primary health-care facilities.

[Table 4] shows that there are statistically significant differences in scores between nonaccredited and accredited primary health-care institutions except the MQ construct, overarching process domain. In contrast, no statistically significant difference in scores was found in secondary health-care institutions. When we consider the overall scores of secondary health-care facilities, it can be assumed that accreditation has impacted the process domain of primary health-care institutions only, even though W and C hospitals shows an impact of accreditation in three constructs.
Table 4: Kruskal-Wallis test for significance for process domain at different categories of facilities

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   Discussion Top

This study was conducted to examine the impact of accreditation in Kerala's primary and secondary health-care facilities under the public sector. The study found that accreditation impacts all Structure, Process and Outcome domains of health-care delivery at the primary healthcare facilities, and this result is significant, particularly when Kerala receives global appreciation for the health-care model for containing COVID-19 by effectively using its primary health-care facilities. Further, the study results confirm the Donabedian model[22] that structural and interpersonal elements of a health-care setting impact PS.

Despite the remarkable achievement in primary care facilities, secondary care facilities fail to show considerable impact of accreditation. This outcome is debatable when satisfaction is “an expression of the patients” overall judgment[21] on “how well” the services provided and reflects patients' perceptions,[11] particularly when accreditation is expected to be a catalyst to quality enhancement and satisfaction. It is to be noted that W and C hospitals, being the next referral point of CHCs, could trigger PS and shows an average impact on some constructs under and structure and process domain. This is perhaps due to the increased facilities available for the pregnant women at these centers, the specific processes of care received by them and the quality of communication.[24] Further, Montagu et al.,[25] found that poorer and less educated women are more likely to deliver in lower-level sites and their satisfaction depends on the successful delivery of a baby, and they will have lower expectations which can be met easily.

Despite the slight positive response of W and C hospitals to accreditation, the study is in line with the finding of El-Jardali et al.,[16] who found that accreditation impacts hospitals with significant differences across hospital size. The study shows that facilities intended to deliver more specialized services have not been impacted by accreditation, which contradicts the finding of Alkhenizan and Shaw,[26] who established the benefit of accreditation in quality enhancement in larger hospitals. Reasons may be a limited supply of workforce, equipment and medicines, limited drug supplies and faulty equipment, high staff turnover, and workload.[16] It can be assumed that accreditation is a step toward quality enhancement, especially in tangible terms[11] but not necessarily a predictor of quality.[13]

The study revealed that, overall accreditation has an effect in structural aspects than the interpersonal domain. The service characteristics of the health-care aspect are often misconstrued, and consequently, the accreditation effort will be concentrated on improving tangible dimensions. This may be due to the misconception of the implementing agency that the patients will be content if the physical infrastructure is made appealing.

The results demonstrate four aspects. First, the success story of primary health-care accreditation in Kerala and the other successful models (Jordanian, Egyptian, and Saudi Arabian) may be examined before implementing accreditation at speciality and referral secondary care centers. Second, many of its 33.3 million population, especially women and children and those with a marginal income, seek health care from public sector hospitals in Kerala.[27] Maya[28] observed that average in-patient expense per person in the private hospital in Kerala is Rs. 22,989, whereas government sector cost is Rs. 11,065. The cost of an outpatient visit is Rs. 525 in private and Rs. 391 in the public sector hospital. Therefore, financial botherations of the vulnerable population must be considered seriously to get a better response in the structure domain. Third, health care transformation must be integrated from the primary to tertiary level with benchmarked indicators of quality dimensions. Being the immediate referral centers of primary health-care facilities, secondary health-care facilities must be transformed into quality care centers through rhetoric action as the level of patient expectation on specialty care tend to be more. Finally, as Rahat[23] suggested, hospitals must be empowered with more resources and knowledge “along with development and growth in determinants of quality in terms of structure, process, and outcome of the service” before stepping into the accreditation process considering the fact that one PHC serves for every 30,000 population, one CHC for every 120,000 population, THQH/THS for 200,000 population and one GH/DH for entire district population.[29] If to receive the expected outcome from the accreditation process, there is a need for a rhetoric activity to transform the structural and procedural aspects of health-care delivery.

Findings from this research may provide important insights for redefining priorities while implementing or planning to implement accreditation in Kerala or elsewhere and forms a base for policy development in health-care reforms. As a limitation of the study, the data collection period witnessed the outbreak of Nipah fever in Kerala, affecting the accessibility of data sources from the medical wards. Further, there was only one GH accredited hospital in Kerala, which might have affected the result. To honestly assess the impact of accreditation, future research may include more data from the same strata making the comparisons more valid and representative.

   Conclusion Top

Accreditation can produce a positive repercussion in the hospital as a whole. Nonetheless, if to guarantee an expected outcome from this long and expensive process, the authorities must consider accreditation as a means of holistic and continuous transformation. Structure and process domains are the two sides of a coin and eventually contribute to PS. In order to create an increased public acknowledgement, the authorities have to intensify their monitoring and supervisory roles with an unwavering urge for excellence while implementing accreditation.


The author thanks the Indian Council of Social Science Research (ICSSR), New Delhi, India, for assisting this study through a Minor Research Project.

Financial support and sponsorship

This research work is part of the Minor Research Project funded by the Indian Council of Social Science Research (ICSSR), New Delhi, India [F.No. 02/349/2016-17/RP].

Conflicts of interest

There are no conflicts of interest.

   References Top

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[PUBMED]  [Full text]  
Joseph S. Quality Healthcare Access to the Poor: Impact of Hospital Accreditation in Patient Satisfaction in Public Healthcare Delivery of Kerala. New Delhi: Indian Council of Social Science Research (New Delhi, India); 2018.  Back to cited text no. 27
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  [Table 1], [Table 2], [Table 3], [Table 4]

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