84 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) ISSN (Print) 2313-4410, ISSN (Online) 2313-4402 © Global Society of Scientific Research and Researchers http://asrjetsjournal.org/ Qualitative Study of Attitudes of Healthcare Professionals Regarding Accreditation and Quality, in the Pre- accreditation Period in R. Macedonia A. Petrusevskaa*, V. Dimitrievskab, E. Zisovskac, M. Spasovskid aCorresponding author: Aneta Petrusevska, MD, dermatovenerologist, Clinic Dr. Ancevski; PhD student at the University “Ss. Cyril and Methodius” in Skopje, Macedonia. bVera Dimitrievska, Phd, University of Groningen. cElizabeta Zisovska, MD, PhD., professor, Agency for Quality and Accreditation of Healthcare Organizations in R. Macedonia. dMome Spasovski, MD, PhD, professor, Institute of Social Medicine, Medical Faculty, University of “Ss Cyril and Methodius, Macedonia. aEmail: anetakokaleska@gmail.com bEmail: v.dimitrievska@rug.nl cEmail: elizabeta.zisovska@ugd.edu.mk dEmail: mome_spasovski@yahoo.com Abstract The healthcare system in the Republic of Macedonia has planned to commence accreditation of the healthcare organizations. The Government of Macedonia chose to establish its own hospital accreditation systems. The objective of this study is to understand the attitudes of healthcare professionals in hospitals in Macedonia, to gain understanding of the value of accreditation on quality of care as perceived by the staff members and the possible strategies to improve implementation of accreditation , in a pre-accreditation period in R. Macedonia. We chose a qualitative research method and study explorative in nature to see the perceptions and opinions of providers. We used purposive sampling and included health care providers from tertiary health care level. Semi- structured interviews with open questions were used as research tools. ------------------------------------------------------------------------ * Corresponding author. http://asrjetsjournal.org/ American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 85 A total of 30 themes emerged during the coding and were grouped in 6 main domains - Institutional, organizational and management settings; Financial issues; Education; Normative regulations; Professionalism,Quality of care and services- which jointly gave an insight to the perception about accreditation of health care organizations in Macedonia on a tertiary level. We can conclude that the healthcare providers in our study perceive accreditation as a tool, which can catalyze the process towards improving the overall performances in a healthcare organization towards achieving the end goal to deliver quality services to the patients. Keywords: pre-accreditation period; accreditation; quality; perceptions of healthcare professionals. 1. Introduction Quality in healthcare is one of the issues immensely considered by all stakeholder groups in the healthcare system. One of the most used methods for promoting quality at the healthcare organizational level is accreditation [1,2 ]. Accreditation is a process where an organization is assessed by a set of pre-determined standards [3,4]. The main goal is emphasis on the delivery of quality products or services in the healthcare organizations, which are adequate to consumers, funders, and stakeholders [5]. In societies where accreditation has not yet been introduced, there is a lack of evaluating and monitoring for quality of services delivered to patients [6]. The term quality in Macedonian terminology is defined as an extent in which medical services for the patients are delivered in certain economic conditions, comply with the latest medical data , achieving most favorable results and positive outcomes in improving the health status of the client, in the same time trying to maintain a balance between the risk and the benefit of the given therapy or the treatment [7]. Improving quality is defined as a philosophy of the organization which is trying to meet the needs of the clients and even to overcome their expectations with the help of structured processes which selectively identify and improve all the aspects of the service delivered [8]. Thus, it is assumed that managing quality in healthcare organization has to go together with the quality in delivering medical services, bearing in mind all the diverse aspects that have to be considered and monitored in the administrative and clinical aspect of the functioning of one hospital. Hospitals are considered extraordinarily complicated organizations to be coordinated and managed. Managers, are the representatives of the formal authority and their power is perceived as influential in the hierarchy of office, but is perceived by the healthcare givers as far less important than the doctors’ hierarchy of medical achievement [9].Going in the same line with Glouberman and Mintzberg, 2001, hospital managers which are considered outsiders regarding the clinical operations (unless, of course, they have clinical experience themselves), are left to manage resources — budgets, beds, jobs, administraive interventions with overall little effect on the actual delivery of service and health care. Can these two aspects (administrative and clinical) meet on the ground for one common determinant – the health of the population? Can the changes be suited and tailored based on the attitudes and perceptions of the American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 86 medical personnel so that they can be perceived as changes that will truly lead to quality? Health organizations implement changes in order to achieve better quality, and to be successful, it is crucial to be accepted by the biggest possible number of employees in the organizations. The body of literature showed that qualitative studies have evaluated the attitudes and the perceptions of various aspects of delivering healthcare services [15] . Healthcare accreditation started in 1918. Since the 1980’s there has been a marked increase in expansion globally, the accreditation organizations now existing in over 70 countries [16] . WHO (2003) did a survey, which was reported at a global level, is a review about accreditation and quality. It has been announced that there are at least 33 national accreditation programs in 29 countries, out of which a quarter are still in development and are not operational, almost 30% are in Europe, but none in the Eastern Mediterranean region. 1.1 Accreditation of Healthcare Organizations in Macedonia The healthcare system in the Republic of Macedonia has planned to commence accreditation of the healthcare organizations, too. The Government of Macedonia established an agency for accreditation [17] in July 2014. The agency prepared national accreditation standards accepted by the Government of the R. Macedonia. The Government of Macedonia chose to establish its own hospital accreditation systems, as it has already being done in 28 countries [18]. The process of accreditation is expected to be introduced in hospitals providing secondary and tertiary health care services, gradually to encompass all of the health system, in both the public and the private sector. The period before the introduction of accreditation in health care in Macedonia, is considered vulnerable in the context of organizational changes and acceptance of certain standards, which will lead to quality as part of an accreditation process. The aim of the study was to understand the attitudes of healthcare professionals in hospitals in Macedonia and to gain better understanding of (a) the value of accreditation on quality of care as perceived by the staff members ( nurses, doctors, managers) and (b) the possible strategies to improve implementation of accreditation , in a pre-accreditation period in R. Macedonia. There is a gap in the research literature about the perceptions of the health care personnel regarding the accreditation process in a pre-accreditation period. This qualitative study about attitudes of hospital staff in Macedonia regarding accreditation and quality before introducing national accreditation of hospitals by law, is among the first of this kind in Macedonia and in the region. 2. Methods 2.1 Study design We conducted the research from September – December 2014 in 17 health care organizations in Macedonia. American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 87 Semi-structured interviews with open questions were used as research tools. The questions from the interview tool included questions on quality, patient satisfaction, knowledge about the process of accreditation and expectations from the accreditation, organizational changes leading to quality. The researcher conducted the interviews in duration of one hour. The data used in this study are part of a bigger study which was being performed in six cities in Macedonia with main goal to assess the perceptions about accreditation among health care providers. The overall study included 402 participants out of which 100 were interviewed with open questions. Two types of semi-structured interviews were performed: one group of 50 participants including nurses and technicians (lab technicians, pharmaceutical technicians) as health care professionals and the other group of 50 interview including physicians and physicians with a managerial function as health care professionals.. We chose a qualitative research method because the literature is lacking in this field and we wanted to shed a light on nuanced issues that might link quality of accreditation to policy factors in the pre-accreditation period. We wanted participants to reflect on their opinions and perceptions on accreditation in health care organizations, as well as to include their voices in the research process. We thought that the providers’ insights are valuable as directly affected with the process of accreditation. The study is explorative in nature to see the perceptions and opinions of providers. We used purposive sampling [19], we sought health care providers from tertiary health care level, which will be the most straightforwardly involved with the introduction of the process of accreditation in Macedonia. 2.2 Data collection The sample used in this study was taken from a larger cluster of data for accreditation that are taking part in the aforementioned study as part of the PH study of the author. They were chosen from the bigger pool of data for this comprehensive study because we thought they are closely familiar to the process of accreditation. Participants felt comfortable with the interviewer and shared their opinions about accreditation process about to start Macedonia. Prior collecting the data for this study the researcher obtained an informed consent for participation in the interview. Participants were recruited using gatekeepers and snow bowl strategies through providers working in tertiary health care level. [19,20]. Accordingly, study participants were identified on transcripts by pseudonyms only to ensure confidentiality [21]. Transcripts could not be linked to any personal information of the participants. Only the researcher and the supervisors have the access to the stored data. 2.3 Data analysis The interview transcriptions were analyzed using qualitative data software Atlas.ti and then coded using constant comparison method of qualitative analysis to identify inductively and deductively emerged codes. In the next round, the codes were grouped together in code families and their relationships, which derived in grouping of six emerged domains. These six domains appeared together with the emerging themes in each domain showed the perceived process of accreditation of health care organizations in Macedonia. The quotes used in the study were checked with the supervisors and researcher. Two coders were assigned to code American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 88 interviews separately from the interviews. The first cycle of coding included identifying codes from the interviews based on the study aims and identifying inductive and deductive codes. The second cycle of the coding was comparing codes and developing code structure. After the finalization of the code structure, the team discussed several times the dissimilarities, perceptions of codes and achieving agreement for grouping the codes and making code families and their relationships, which followed in the emerging of 6 overarching domains of accreditation process depicted in the next sections. 2.4 Ethical aspects The survey was conducted based on confidentiality, anonymity and voluntary participation. All participants received a written explanation for the reasons for the investigation and for the steps taken to preserve their anonymity. Understanding the objectives of the research and the will to conduct the interview are the components of the voluntary compliance. Written informed consent was not required to preserve the anonymity of the participants. None of the reports prepared based on data obtained from the study does not contain information to identify any of the participants. 3. Findings A total of 30 themes emerged during the coding and were grouped in six main domains. which jointly gave an insight to the perception of the accreditation process of health care organizations in Macedonia on a tertiary level. The first domain emerged as ‘Institutional management and organizational settings’ representing the institutional settings of health care organizations, which shows the context for the accreditation process. The institutional structure is perceived by the majority as a contributor to the base for a good accreditation system in the health care environment. The next three domains perceived generlly are financial resources, education (trainings) and normative part. The financial resources are always crucial in maintaining of any activities; the necessity of the financial issues in the health sector becomes very relevant in the transitional period of Republic of Macedonia. In parallel with the financial issues, the educational part of the health care professionals plays an enormous role for the health care system itself. Along with the education and the financial issues, the normative acts and procedures are key points in establishing good accreditation process in the health care system. ‘Professionalism’ is reflected in responsibility, motivation to work with fragile people, being loyal in your everyday work. Ethical virtues as part of the health care work are relevant in accreditation system of the health care. However, in the general literature related to accreditation, we find that efficacy segment has been seen as the essential feature in the accreditation policy. ‘Quality’ concepts in the health care system are considered as part of the accreditation tools, which are crucial for establishing good accreditation system. Quality reflects on the fulfillment of the checkpoints and evaluation during health care accreditation On the other hand quality of delivered services to the patient is considered to be one of the essential part of the quality issue judging by most of the answers of the interviewees. American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 89 These six domains have been discussed and embraced the perceptions of the participants during our research process; we will present them in the following sections: 3.1 Institutional, organizational and management settings The Institutional, organizational and management settings domain implicitly emerged as a foundation for establishing the accreditation process reflected by the participants upon their experiences and perceptions in the health care institutions. Themes in this domain included coordination, good working structure, teamwork and sustainability of the whole system. Macedonian health care system is in its final phase of preparation to start the accreditation process. The interviewers shared their experience and opinions about the process; described the current shortcomings that are necessary to control one health care institution. Moreover, the interviewers have expressed their concerns that the coordination and management concepts are lacking as there are bad working conditions, choosing managers who are not educated enough, nor up to their task, changes of the management team reflected by the actual political party in power. Some statements are presented below related to the first domain: Responsible persons to be appointed to the managerial positions. In our public hospitals, we are seeking jobs for certain people but not selecting the right people for the job - ID 175 (doctor), Skopje ‘Good and successful management team, educated for health management is needed, who will have a mission to implement good quality in the health organization’ - ID 321(nurse), Kumanovo ‘To make reorganization, respecting the hierarchy and unified codex for acting , detecting weaknesses and improving of the work based upon these weaknesses, respectively making plan and program of improving and conrtolling of work ‘ ID 89 (technician), Gostivar ‘Firstly, material conditions have to be on a certain level, because, in a hospital where sewer discharges bad odor and insects are found in the premises , it is pointless to talk about accreditation ‘ ID 148 (doctor) , Skopje During the interview, the interviewees complained of bad relationships and lack of communication with the colleagues about professional issues. The interviewees expressed worries about how the communication would influence the accreditation process in near future if wanted to be fully implemented. The health care professionals perceived that good teamwork; cooperation among the professionals and staff, good prepared work plan could give quality of work. ‘There should be a much bigger cooperation between the management and the staff and good coordination between the staff about the interdependent tasks and respecting the issued protocols and standards’ ID 8 (doctor), Shtip. American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 90 3.2 Financial issues Another domain that lies on the path of the accreditation process in the health care is the financial issues.Themes that appeared into the financial issues included material support, allocated budget, low salaries and equipment. Some participants have reported that not enough budgets for new equipment, lack of financial means and low salaries could delay the implementation of the accreditation process. Their main concern is the budget and the need to update the current equipment. Participants reported: ‘We need better working conditions and a need to introduce new methods for diagnosis and treatment, but a precondition for this is a better budget planning , better material support, enough personnel and successful accreditation’ ID 73(doctor), Skopje ‘If a doctor has a good salary he will be satisfied and this will reflect in the satisfaction of the patients too’ ID 238 (doctor), Skopje 3.3 Education The emerged themes in the education domain are: lack of continues training, skills and internships. Nearly all health care professionals observed that the knowledge and the education of the health care providers have been outdated and the continuous medical education is a priority. As one professional stated, ‘Professional training and continuous medical education and standardized services are indispensable’ ID 58 (doctor), Bitola 3.4 Normative regulations Normative regulative represents one of the important aspects in the accreditation process. As a major issue for accreditation, the participants acknowledged that legal aspects are forming the base for commencing the process. The themes that emerged in this domain are protocols, standards, procedure and promotion of accreditation process. The health care professionals in general expressed their perceptions about the normative regulations and the need for them to be established. Low quality of care in their opinion is among other things a result of lack of standard procedures for providing services in the health care system in Macedonia. ‘ Work health standards are needed; continuous and updated innovations in the medical sector approved by the WHO’ ID 395 (nurse), Skopje ‘The approved standards need to be implemented and evaluated by professionals so to be sure they are fully and accurately implemented. otherwise, measures should be established for quality assurance and maintaining of safety’ ID 66 (nurse), Skopje Introducing standards and normatives which will be respected from the healthcare givers as well as those who American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 91 receive the services. ’ interview no: 94, Skopje ‘Promotion of the accreditation process is needed and regular meetings with the whole staff where all the questions about accreditation should be an answered from relent professionals chosen from the team and educated to implement accreditation in the organization’ ID 312 (doctor with managerial function), Kumanovo 3.5 Professionalism As a main goal for the accreditation process, the participants seemed to draw the importance of being professional and responsible for the provided health services. Emerged themes included: motivation, responsibility efficacy, trustworthiness and being loyal. Participants in general did not know to explain details about being professional and responsible in the health care institutions. The health care professionals expressed a dissatisfaction of the general awareness of being responsible for the working tasks, ‘Increasing of mental awareness for the employees pertained to responsibility for own working tasks should be obtained’ ID 390 (technician), My Hospital, Skopje ‘Healthcare staff needs to be more polite, affectionate, with more respect for the patient‘ ID 388 (nurse), Skopje Low motivation was an issue for health care professionals and key informants. However, in overall, in Macedonia, the motivation drive among health care providers is perceived as valuable not only in terms of professional, but also for personal development. The lack of motivation among health care professionals demonstrates low level of professionalism on the way to respond to the needs of the clients/patients. ‘More motivation is needed, increasing of the salaries among doctors and stimulation with awards is important for the accreditation process and quality in general’ ID 166 (nurse), Skopje The next issue that was stated by the health care professionals, which in their opinion influences the accreditation process, is that moral virtues as part of the code of conduct are not on the top level among professionals. This was evidenced during the interviews, when we asked participants to state which their perceptions of a successful accreditation process are. One participant explained, ‘Compromise among professionals, trustworthiness and efficacy are relevant for the accreditation process.’ ID 195(doctor with managerial function), Skopje 3.6 Quality of care and services This section reflects on the quality, either in terms of quality of care provided to the patients or services available for the patients. In this domain, the main emerged themes are: patient satisfaction, patient culture, communication doctor vs. patient, staff satisfaction. We observed the patient satisfaction through the eyes of the healthcare providers about the quality of the services they provide to the patients in their organization. American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 92 Related to this issue, the health care providers said : ‘Polite conduct, enough time so the patient can explain the problem with respect for the time that belongs to him, building confidence, fast, efficient and professional service should be delivered to the patient’ ID 789 (nurse), Skopje ‘Into today’s environment there are no quality measures, only quantity. Numbers are the basic and most important priority’ ID 26 , Tetovo. ‘There has to be full satisfaction of the medical team in order for patients to be satisfied, and for this to be achieved all has to change, working conditions, there has to be team work, good coordination between staff and of course higher salaries,’ ID 228, (doctor) Shtip From the perspective of the medical staff the patient culture also needs improvement. Many of professionals have similar perceptions as the perception of these healhcare providers : ‘Quality is measured through patient satisfaction , which is not altogether right because the self-will of patients sometimes disturb the procedures and the health care system itself ' ID 157 (doctor), Skopje ‘There needs to be respect and understanding between doctors and patients but patients as much rights as they are given are never satisfied enough’ ID 45(nurse), Bitola ‘Patients are satisfied if the need they set their mind toward is satisfied but the perception of the patient about quality not always matches the perception of the doctor’ ID 193 (doctor) , Skopje Communication problems among the providers and patients are evident among most of the interviewed professionals. Good and professional communication between doctor and the patient, respect of each other on the both sides is needed , giving correct therapy through the individual approach, complete information for the disease and availability of the doctors anytime is more than needed’ ID 34 (doctor), Skopje 4. Discussion and conclusion The study research that we have presented contributes to the understanding of the perceptions and experiences of the health care professionals pertain to the accreditation process in Macedonia in a way of assuring good quality. This research intends to show an emic perspective of the participants through their opinions and attitudes, which help us in understanding the diverse expectations of the providers, by explicitly showing us the perspectives of accreditation trajectory as a tool for quality in the health care services. The concept of professionalism has appeared explicitly in the study as one segment of accreditation. Because adequate professional experience and knowledge skills are essential for successful accreditation process, specific knowledge and moral virtues were often expressed as lacking by the participants. Thus, professionalism American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 93 is relevant part of the accreditation strategy. Our findings illustrate that professionalism as a concept was used as a strategy to improve the quality of care in the existing body of literature. Many eminent scholars have defined this concept of professionalism. According to Association of American Medical Colleges the professionalism has been delineated ‘as a work in which the workers must be implicitly trustworthy and must pursue their work as ‘virtuous undertaking a moral activity’ and the health practice is perceived ‘guild’ aimed at as a social good [22]. In the context of health practice, the Royal College Working Party, the definition of professionalism is ascribed more as a core of values, behaviors and relationship towards clients based on trust and mutual respect and responsibility [23]. However, in all aforementioned versions of definitions they are representing one part of the concept of professionalism, there are overlaps within, pursuing one common goal to serve humans in fragile state showing constantly their high degree of competence, accountability, skills and knowledge [22]. However, the professionalism concept is always in interaction with the professional skills and the ethical virtues, which determines one part of the accreditation path. Considerably, more participants claimed a low motivation in their work in order to respond to the needs of patients. In our study some participants perceived difficulties in interaction on both level among their colleagues and patients. These findings are in relation with the current discussion in the literature on patient interaction among health care professionals, including the patient culture and interaction as part of the quality of care. Despite the welcoming Macedonian accreditation strategy for the health care institutions, it seemed as if this is to be considered as an administrative demand, which will burden the work for the health care professionals rather to shed on paying an attention in the same time on the communicative skills segment. Some of the management settings delineated in the findings support previous literature on institutional and organization set up factors influencing in the implementing the accreditation process, while others were unique to the context of our study. Examples of others studies identified in other contexts included the education, normative regulation, financing issues [23]. This study highlights also how management in the health care organizations could be relevant for a quality of care as an inseparable link of the accreditation process. This paper provides rich material from the health care professionals to understand better the concept of professionalism in assuring quality of care and the importance of the context in one accreditation process. Quality of care and services are reflected on the micro level of one context, where the linkages between the doctor and the patients are crucial. This quality of care, however, is conditioned, by the educational system and virtuous skills and that governs the successfulness of the accreditation. Although, the moral virtuous skills were not shown to be of defining importance in the initial accreditation process, it appears that the ethical part and virtuous determine future quality of care in the health care organizations. Research from professional’s perspective thus helps us to shed light on how the professional knowledge and good communication skills play immensely role for the patients and society. In the context of health practice, the Royal College Working Party, the definition of professionalism is ascribed more as a core of values, behaviors and relationship towards clients based on trust and mutual respect and responsibility [23]. However, in all aforementioned versions of definitions they are representing one part of the concept of professionalism; there are overlaps within, pursuing one common goal to serve humans in fragile state showing constantly their high degree of competence, accountability, skills and knowledge [22]. American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 94 In overall, we can conclude that the healthcare givers in our study perceive accreditation as a tool, which catalyzes the process towards improving the overall performances in a healthcare organization towards achieving the end goal to deliver quality services to the patients. In this process the management as a leader has the role to present and fully explain the presented standards and protocols but also to cooperate and take into consideration the remarks from the healthcare providers in order to suite the process in a way acceptable to them. The adopted standards and protocols have to be clearly understood by the personnel and the patients as the quality tool to be accepted. Interrelations also can be formalized into working protocols, which does not leave space for personal interrelations to confront the work. The clinical guidelines can be formalized as working standards as to not leave space towards wrongdoing . Budget planning is essential for improving the working conditions and the stay in hospitals but also for updated equipment and regular education and training of personnel. Future studies are needed to evaluate the results before implementing accreditation and after this process to show the true value of the accreditation as a tool towards quality in healthcare organizations in R. Macedonia. 5. Constraints and limitations A limitation of our conceptual framework is that while it explores professionalism as a fundamental cause of accreditation process in one developing health care system, it does not explicitly address the role of patients and their interaction with the health care professionals. Patients in the health care system in Southeastern Europe are in a position of constant change and reforms in the health care systems after socialist period, lack of information for their rights and lack of still adequate and suitable services. Thus future research should focus on the interaction of patients and health care professionals. A further limitation of our research is that we did not conduct focus groups with health care professionals on primary and secondary health care level, so we could not draw comparisons between the experiences of the two groups. The quality of l health care has been an ongoing issue for the overall population in the country, and thus some of the experiences described by other health care professionals may to some degree reflect overall low quality of care rather than an experience specific to managerial staff of the health care institutions; however, the information we collected suggests that the overall strain put on the health care system due to lack of resources may in some ways increase quality of treatment. For example, it is the lack of resources that in part creates the need for “connections” to access care, a situation that disproportionately impacts some patients who are less likely to have connections due to their marginalized place in society. Nonetheless, future research might benefit from investigating the experiences of majority groups in this country as well. 6. Significance The recent studies are increasingly focused with quantitative data and availability of health care services, whereas neither of these studies covered comprehensively, health practitioner’s perceptions toward accreditation process and practices. There is a lack of understanding about the interaction of practitioners with the health care system. This study takes a relevant approach focusing on attitudes of providers and examining their knowledge tied in with government policy. The study will provide a new contribution to the scientific knowledge and fill the gap in the literature in a prezccreditation period. American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2016) Volume 18, No 1, pp 67-96 95 Our study is the first study on the evaluating attitudes and perceptions of health care professionals in the dawn of implementation of accreditation in Macedonia. The design had several important starting points. First, the professionals who are providing services were involved in the study since its designing. Second, we gathered a data from various profiles in the health care organizations as, doctors, nurses and administrative staff in order to gain various perspectives about the accreditation. This paper provides rich material from the health care professionals to understand better the concept of professionalism in assuring quality of care and the importance of the context in one accreditation process. Policy implications can be drawn from the health care professionals attitude used for our theoretical model in efforts to start the process of accreditation in Macedonia. Competing interest The authors declare that they have no competing interests. Author's contribution PA and DV carried out the qualitative study , participated in the design of the study , sequence alignment and drafted the manuscript. ZE participated in its design and helped to draft the manuscript. 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Numbers are the basic and most important priority’ ID 26 , Tetovo. ‘There has to be full satisfaction of the medical team in order for patients to be satisfied, and for this to be achieved all has to change, working conditions, there has to be team work, good coordination between staff and of course higher salaries,’... ‘Quality is measured through patient satisfaction , which is not altogether right because the self-will of patients sometimes disturb the procedures and the health care system itself ' ID 157 (doctor), Skopje References