408 | pISSN: 1858-3598  eISSN: 2502-5791 

 

Jurnal Ners 
Vol. 14, No. 3, Special Issue 2019 
http://dx.doi.org/10.20473/jn.v14i3(si).17218 

This is an Open Access article distributed 
under the terms of the Creative Commons 

Attribution 4.0 International License  

Systematic Review 

The Impact of Hospital Accreditation on Nurses' Perceptions of Quality of Care? 

Tejo Trisno, Agit Pratama Putra, and Sena Wahyu Purwanza 

Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia 

ABSTRACT 

Introduction: Accreditation is the recognition of the quality of services that 
have met the National Hospital Accreditation Standards. In implementing 
hospital accreditation , it covers patient safety goals, patient-focused service 
standards, hospital management standards, national programs and 
integration of health education in hospital services. How is the impact of 
hospital accreditation on the quality of care, especially nursing services in 
accordance with the perceptions and attitudes of nurses in hospitals. 
Therefore, it is necessary to identify the impact of applying hospital 
accreditation in accordance with nurses' perceptions and attitudes towards 
nursing services. 

Methods: For this reason, articles data with a for publication from 2008-
2018 are needed, of the 418 systematic literature articles taken from Scopus, 
Science direct, and Proquest. There are 15 articles chosen to search for 
literature with keywords; the impact of accreditation on nurses' perceptions 
and attitudes about the quality of care. 

Results: Five of the 15 articles that fit the design criteria that address the 
impact of hospital accreditation according to nurses' perceptions and 
attitudes in improving nursing services. 

Conclusion: The study results show that hospital accreditation make a 
nurses perception the quality of care. Quality of care is the one of impact 
from hospitals accreditation. Nurses in accredited hospitals feel a higher 
level of quality of health services. 

ARTICLE HISTORY 

Received: Dec 26, 2019 
Accepted: Dec 31, 2019 

KEYWORDS 

accreditation; quality service; 
hospital; nursing service; attitude; 
quality of care 

CONTACT 

Tejo Trisno 
 tejo.trisno-2018@fkp.unair.ac.id 
 Faculty of Nursing, Universitas 
Airlangga, Surabaya, Indonesia 

Cite this as:  Trisno, T., Putra, A.P., & Purwanza, S.W. (2019). The Impact of Hospital Accreditation on Nurses' Perceptions 
of Quality of Care?. Jurnal Ners, 14(3si), 408-412. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17218 

 

INTRODUCTION  

Accreditation, defined as public recognition by 
National Health Accreditation Commission 
accreditation standards achievement by Health 
Organizations, through assessment by external and 
independent survivors appointed by the ministry of 
health (Reisi, Raeissi, Sokhanvar, & Kakemam, 2019). 
Developing countries often use hospital accreditation 
to ensure patient quality and safety. However, the 
adoption of hospital accreditation standards is 
considered too demanding in the field of health 
services. In addition, the empirical literature on the 
benefits of accreditation is rare and this is the first 
empirical interrupted time series analysis designed to 
examine the impact of health accreditation on 
measures of hospital quality (El-jardali, Jamal, 
Dimassi, Ammar, & Tchaghchaghian, 2008). The 
National Hospital Accreditation Standard is a method 

for viewing and assessing the quality of health care 
organizations using external surveyors and published 
standards.  

This is often compared to an internal review 
process where members of the organization develop 
their own methods and standards to assess quality. 
There is little evidence available to verify which of the 
two forms of review have an impact on clinical 
outcomes and patient care. The accreditation process 
focuses more on risk management and patient safety 
than the previous steps to ensure the level of 
compliance with standards (Griffith, 2018). Patient 
safety is important to consider in health care. Thus, 
various programs are included by health institutions 
to monitor their services including patient safety 
procedures. Accreditation is one program to monitor 
health services and evaluation processes that are 
internationally and nationally recognized that are 
used to assess, promote, and ensure quality and 

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JURNAL NERS 

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efficient patient care and patient safety (Top & 
Tekingündüz, 2015).  

Accreditation is increasingly being applied as a 
tool for the government to regulate and guarantee the 
quality of service quality and patient safety (Alswat et 
al., 2017). Hospitals must implement, develop and 
evaluate an effective, sustainable quality assessment 
and performance improvement program in all 
hospitals, based on information systems (SIM RS). 
Hospital management must ensure that the program 
improves patient quality and safety in hospital 
services, to involve all hospital departments and 
services (Bahrami, Chalak, Montazeralfaraj, & 
Dehghani Tafti, 2014). Improving market orientation 
and patient safety has become a major concern for 
nursing management. For that nurses, must build a 
climate of improving quality and patient safety is the 
key to improving nursing quality (Nomura, Pruinelli, 
Da Silva, Lucena, & Almeida, 2018).  

Health care facilities are always associated with 
increased patient safety risks. In the past, the 
functions of risk management and quality 
improvement often operated separately in health 
service organizations. In addition, each individual 
who is also responsible for each function has a 
different reporting path. Nurses' perceptions of 
improving quality and patient safety are important in 
health care organizations. In addition, some hospitals 
have admitted that patients will receive care with 
guaranteed safety. High-quality care is very 
important to protect the institution's financial assets 
and also to lose, so it is very important to have risk 
and management plans. In this case, risk management 
and patient safety professionals correlate in close 
working relationships (Greenfield, Pawsey, & 
Braithwaite, 2011).  

The nurse is responsible for ensuring that caring 
for the patient with safe care, no danger has occurred. 
Nurses have an important role in patient safety and 
reduce medical errors. In the past few decades, 
patient safety has become a high priority health 
system problem, because of the high potential for side 
effects in health facilities because it shows the 
challenge of a weak patient safety culture, in 
hospitals. Therefore, this problem must be integrated 
into all policy makers and managerial initiatives in 
our health system, as a top priority (Zyoud et al., 
2019). Nurses as the largest group of healthcare 
providers in offering direct patient care. The purpose 
of this study was to describe nurses 'perceptions of 
the culture of patient safety after hospital 
accreditation, the correlation between nurses' 
perceptions of hospital accreditation and improving 
the quality of nursing services. 

MATERIALS AND METHODS  

This systematic review is carried out following the 
steps based on the PRISMA Statement, namely (Reisi 
et al., 2019) Formulating research questions, (El-
jardali et al., 2008) Choosing relevant research terms 
and formulating search phrases in consultation with 

information specialists in the health sciences, 
(Griffith, 2018) Planning a search strategy, (Top & 
Tekingündüz, 2015) Approve inclusion and exclusion 
criteria, (Alswat et al., 2017) Conduct systematic 
searches in electronic databases, (Bahrami et al., 
2014) Select appropriate research articles and [7] 
Conduct quality assessments of studies chosen for 
review (Moher et al., 2009). Search Strategy and 
Inclusion Criteria Systematic searches were collected 
from ProQuest (347,327 journals),  

Scopus (418 journals), and ScienceDirect (592 
journals). Search is done using a combination, using 
Boolean terms and quotes to qualify for this study, 
this article uses a cross-sectional method, one article 
uses multiple regression analysis, one article uses 
study intervention and one article uses descriptive 
research design methods and reviewed design 
literature and answered research questions. Articles 
that are not relevant to the research questions or not 
related to nurses' perceptions related to the patient 
safety culture and hospital accreditation era will be 
excluded from this study (as shown in Figure 1). In 
the screening process, we get 15 full text articles that 
meet the requirements of the search key words that 
match those included in the study, and also according 
to the purpose of this review. 

Finally, seven (n = 5) articles are selected from 
this selection process. To sharpen the selection 
process and find the expected objectives in this 
literature review, we limit the articles in various 
electronic databases from various countries that have 
a diversity of nurse characteristics and various 
hospital policies related to the patient safety culture. 
It aims to get the latest information from the topic of 
nurses' perceptions of the patient safety culture in the 
era of hospital accreditation, because in this era, it 
cannot be denied that in all regions of the world, 
hospital accreditation is one of the requirements in 
quality hospital service ratings . In all of these studies, 
the study sample was nurses, according to the 
purpose of this article, and looked at whether there 
were significant changes in nurses' perceptions of 
patient safety culture in the accreditation era, 
because patient safety was the target of assessment to 
obtain accredited hospital status (as shown in Table 1 
). 

RESULTS  

Based on the research subject we found the number 
of respondents was 5311 of nurses, 12.112 survey 
from patients record, 30 staff of health care and 
director hospitals as 638 respondents. Based on the 
location of the study we found all of studies were 
conducted at the hospitals. Based on the research 
design, we found thirteen quantitative studies with 
the type of 9 cross sectional, 2 descriptive correlation, 
2 comparation and 2 types of retrospective. For data 
sources, the questionnaire is the instrument used 
from the thirteen articles and intervention was 
conducted from the two articles. We identified 
several instruments used to measure perception the 



T. TRISNO, ET AL. 

410 | pISSN: 1858-3598  eISSN: 2502-5791 

nurses about outcomes of hospitals accreditation to 
improving quality of care.  

From the results of a review of fifteen articles it 
was found that nurses perceived an improvement of 
quality care in hospitals as an outcome of 
accreditation. In terms of the benefits of hospitals 
accreditation (Reisi et al., 2019), nurses' perspectives, 
hospital managers can facilitate accreditation 
program implementation through financial support, 
strengthening of commitment and accountability, 
solving human resource issues, and stop current 
programs overlapping and revising the accreditation 
program. According to nurses perception that 
accreditation standards should also be revised 
regularly to ensure that they comply with the most 
recent worldwide standards and continue to be 
relevant (El-jardali et al., 2008), the impact of hospital 
accreditation is improve the patient safety level. 
Nurses’ perceptions of patient safety appear to be 
essential. Nurses are important for the improvement 
of the patient safety culture in health care 

organizations. Accreditation has an overall 
statistically significant improvement in the 
perception of the culture of patient safety (Griffith, 
2018; Nomura et al., 2018), Participants’ perception 
of safety climate was positively correlated with their 
attitude toward medication error reporting; this 
correlation strengthened following completion of the 
program (Alswat et al., 2017), Nurses perceptions 
that JCI accreditation may help health systems 
enhance the awareness and ability to prevent MAEs 
and achieve successful quality improvements 
(Bahrami et al., 2014). Hospital accreditation has a 
positive impact on quality results especially on the 
quality of care provided to patients and patient 
satisfaction (Greenfield et al., 2011), nurses have an 
perception that hospital accreditation had a 
significant impact on hospitals’ IC infrastructure and 
performance and accreditation helps teams review 
their work and improve their ideas about what they 
have done . . . it clarifies things for staff and gives a 
sense of direction, clarify issues and be constructive 

Records identified through database 
searching 

(n = 347327  ) 

Additional records identified through 
other sources 
(n = 1110  ) 

Records after duplicates removed 
(n = 4515  ) 

Records screened 
(n = 4025  ) 

Records excluded 
(n = 1515   ) 

Full-text articles assessed for 
eligibility 
(n = 418  ) 

Full-text articles excluded, 
with reasons 

(n = 387  ) 

Studies included in qualitative 
synthesis 
(n = 15  ) 

Studies included in 
quantitative synthesis (meta-

analysis) 
(n =  5 ) 

Figure 1 PRISMA flow chart (Moher et al. 20-09). 

 



JURNAL NERS 

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and offer ideas for improvement, felt comfortable and 
confident to approach the surveyors but they were 
pressured by time to move on . . . much more time for 
discussion is necessary, the overall timetable is 
rushed and often compromised (Sekimoto et al., 
2008; Yildiz & Kaya, 2014). Interventions that help 
hospital administration and managers to provide 
more supportive leadership may facilitate safety 
climate improvement. Hospitals and their units 
should develop more friendly and intimate working 
environments that remove nurses’ fear of penalties. 
Administration and managers should support nurses 
who report their own errors (Zyoud et al., 2019), the 
nurses perception that hospital accreditation 
improvement in the nursing documentation. 
Educational interventions performed by nurses led to 
a positive change that improved nursing 
documentation and, consequently, better care 
practices (Al-Awa et al., 2012).  

 

DISCUSSION 

The perception of nurses on hospital accreditation 
outcomes is an increase teamwork and productivity. 
There needs to be a reward, recognition, leadership 
and commitment to the accreditation of hospitals so 
that it can enchance cooperation in improving patient 
safety (Reisi et al., 2019). The impact of hospital 
accreditation is improve the patient safety. 
Accreditation has an overall advantage over 
certification in clinical leadership and review but 
some of these results are statistically significant 
improvement in the perception of the culture of 
patient safety . Where both systems, active on their 
own, show a positive relationship with quality 
management, the effect in combinations seems to be 
bigger and more significant. The determination and 
evaluation of the patient safety culture level in 
hospitals should be viewed as a continuous process 
where a need for continuous improvements in the 
hospital patient safety culture exists. To improve the 
patient safety level, nurses’ perceptions of patient 
safety appear to be essential. Nurses are important 
for the improvement of the patient safety culture in 
health care organizations. Moreover, some hospitals 
have recognized that providing (Griffith, 2018). 
Nurses' perceptions of the patient safety culture are 
influenced by many factors including internal nurse 
factors and external or environmental factors. 
Internal factors are competency and position in the 
organization and also competence consists of age, 
level of education, and clinical experience. And it is 
classified as an external factor that influences nurses' 
perceptions of the patient's safety culture: leadership, 
hospital policy, teamwork, management support, 
open communication, promotion, and appreciation. 
Hospital accreditation had a significant impact on 
performance and accreditation helps teams review 
their work and improve their ideas (Sekimoto et al., 
2008). Nurses' Perceptions themselves had enough 
staff and resources to provide quality nursing care, 

and had good nurse-doctor relationships and collegial 
Presence of nursing leadership visible and competent 
all factors that are strongly related to the assessment 
of the safety of patient care in their workplace. The 
perception of having enough staff and resources 
might not be consistent with the patient's ratio: actual 
staff, but it seems to be an important factor related to 
how nurses see patient safety in their hospital ward 
or unit. This is a fact that nurses are the largest 
community in an accredited hospital or not, and the 
main point is that nurses are the spearhead of 
hospital services that interact more frequently with 
patients. Thus, the patient safety culture must be the 
commitment of the nurses. In accreditation, patient 
safety is one of the objectives assessed, and is the 
main prerequisite that hospitals must meet various 
size requirements. There is a significant increase in 
nurses' perceptions of the patient safety culture in the 
process and after hospital accreditation. Hospital 
accreditation has a positive impact on quality 
especially on the quality of care provided to patients 
and patient satisfaction (Sekimoto et al., 2008). 
Hospital accreditation make a nurses have a safety 
culture rooted in their awareness, it will be a more 
point in the process of improving the quality of 
hospital services, of course. Nurses part of 
professional caregivers to patients and the most 
energy in hospitals in managing patients 
comprehensively will continue to increase awareness 
in improving the quality and safety of patients in 
hospitals. 

CONCLUSION 

The study results show that hospital accreditation 
make a nurses perception the quality of care. Quality 
of care is the one of impact from hospitals 
accreditation. Nurses in accredited hospitals feel a 
higher level of quality of health services. Nurses' 
perceptions of the patient safety culture are 
influenced by leadership, commitment, and 
supporting strategic quality planning, education and 
training. Another influence of the factors is the 
management of quality and data use compared to 
their counterparts in non-accredited hospitals. In 
accredited hospital perception of safety climate was 
positively correlated with their attitude toward 
medication error reporting. Strengthening the safety 
climate in the workplace is an important step towards 
improving patient safety. At the level of the patient 
safety competency dimension, teamwork and 
communication are significantly related to the 
perceived safety climate. Therefore, increasing nurse 
safety competencies, with an emphasis on teamwork 
and effective communication, can contribute to 
building a strong safety culture. Because there was a 
lack in the reviewed studies used the cross-sectional 
and correlation, well-designed such as qualitative 
should be conducted to more objectively evaluated 
the fenomena of nurses perception about impact of 
hospital accreditation on quality of care.  



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