The Development of the Questionnaire on Health Care Professionals’ Attitudes on Accreditation of Health Care Institutions A

Introduction: Accreditation is a procedure for evaluating the quality of work of a health care institution. It is based on the application of the optimal level of established work standards on health care institutions in a particular area of health care (branch of medicine). As health care professionals are the main carriers during the accreditation process of healthcare institutions, it is very important to evaluate the structure and gain insight into the most important components of their positions regarding accreditation, prior to starting this process. Methods: The study was conducted in two secondary and tertiary level hospitals, one of which is accredited and the other is not. It was designed as an observational study and included a survey of two groups of respondents. The experimental group consisted of employees of a hospital where the process of accreditation had been conducted, while the control group consisted of employees of a hospital where the process of accreditation had not been conducted yet. The survey used an original questionnaire that consists of 23 questions as a tool for measuring the health care professionals’ attitudes on accreditation. The data reduction and structural validity evaluation of the aforementioned instrument was performed by principal component analysis, while its relativity was evaluated using the Cronbach’s alpha coeffi cient. Results: The Questionnaire on Health Care Professionals’ Attitudes on Accreditation with the resulting 10 questions has high structural validity (Kaiser-Meyer-Olkin measure of adequacy = 0.909). The total Cronbach’s alpha was 0.916. By analysing the main components of the extracted ten questions, three factors (components) were identifi ed: (1) the Attitude on the Positive Long-Term Impacts of Accreditation on the Planning, Implementation and Changes of the Overall Concept of Health Care, (2) the Attitude on Increasing Professional Affi rmation and Improving Work Morale, and (3) the Attitude on Improving Communication and Safety at Work. Health care professionals employed in a hospital that had completed the accreditation had signifi cantly more positive attitudes about the process in all of the aforementioned components compared to employees of a hospital that had not completed the accreditation process. Conclusions: The Questionnaire on Health Care Professionals’ Attitudes on Accredi-


INTRODUCTION
Accreditation is a procedure for evaluating the quality of work of a health care institution. It is based on the application of the optimal level of established work standards on health care institutions in a particular area of health care (branch of medicine) [1]. It is considered to be the oldest and most widespread independent mechanism for the external assessment of the quality of work of health care institutions and is implemented in over 70 countries worldwide. Its goal is to provide safe health services of the highest quality [2,3]. As a result of regional and national strategies, the development of the healthcare accreditation programs was intensifi ed in Europe in the 1990s [4].
Th e accreditation process contributes to ensuring the quality and cost-eff ectiveness of health care services. It creates equal or approximately equal conditions for the provision of health care services throughout the health care system, as well as establishing consumer confi dence, and improving overall health care management [4].
Leadership, human resource management, quality management, organizational culture, and safety directly infl uence the accreditation process of health care facilities and are linked to the development of health care facilities [5]. A survey on the importance of accreditation conducted at a hospital in Iran has identifi ed leadership and quality management as the most important predictors of quality [6].
However, employees in health care centers are the main carriers of the activities that accreditation entails, and the success of the process directly depends on their motivation and engagement. Various research projects have shown that personal involvement of employees during the accreditation process signifi cantly increases their interest in improving the quality of work of the health care institution as a whole [7].
In addition, employees' views on the accreditation process are important for the implementation of this process, given that team collaboration is critical for completing the accreditation process [8].
Despite the large body of research conducted in this area, there is still insuffi cient data to form solid conclusions regarding the eff ects of the accreditation process [9]. Th is is why health care professionals oft en express a certain level of scepticism about the eff ects of the accreditation process. Some of them fi nd the process to be too demanding, bureaucratically oriented and expensive, especially with the admixture of marketing methods and strategies [10]. Moreover, some of the recent studies have indicated that the accreditation process of hospitals is associated with a signifi cant increase in stress levels in health care providers [11].
On the other hand, a study conducted at a recently accredited Danish hospital utilised a semi-structured interview. Its goal was to capture a broader range of employees' experiences. Th e study showed that employees found that organizational activities had been improved during the preparation for the accreditation process, and that the hospital was better prepared for new initiatives following accreditation [12].
Generally speaking, it is of utmost importance for the validity of the studies examining health care professionals' attitudes that they do not burden themselves with additional obligations during the research. Given the nature of the work they do and the time constraints their work entails, using an openended questionnaire is considered to be an adequate research approach for examining their views and gathering comments related to the evaluation of the accreditation process [13].
Considering the aforementioned facts, it is of utmost importance to examine the health care professionals' attitudes regarding accreditation before starting the accreditation process [7]. Th is fact was one of the leading motives for creating a valid and reliable instrument that would provide data on health care professionals' attitudes and expectations towards the accreditation process.

METHODS
An observational academic (non-commercial) study examining the health care professionals' attitudes on accreditation, regardless of their own experience of going through the accreditation process, was conducted in February 2016, in Health Center Zvezdara (HC-A) and Health Center Zemun (HC-B). In addition, a cross-sectional study based on the respondents' experience of going through the accreditation process was also conducted. Th e respondents of this study were divided into two groups: the fi rst group consisted of health care professionals from the hospital that completed the accreditation process (HC-A), and the second group consisted of health care professionals from the hospital that did not complete the process yet (HC-B).

Research subjects
Th e survey included two groups of respondents: the experimental group that consisted of employees of a health care institution where the process of accreditation had been implemented (HC-A), and the control group that consisted of employees of a health care institution where the process of accreditation had not been implemented yet (HC-B).
Interviews with health care professionals were conducted over the course of one day. Questionnaires (Appendix 1) were distributed to all of the departments. Th e estimated time for completion of the questionnaire was 10 minutes.

Measurement instrument applied in research
A questionnaire , which consisted of questions that were designed to examine health care professionals' knowledge and attitudes regarding the accreditation process, was applied in the survey. Th e thematic framework for the questionnaire was created on the basis of the literature related to the accreditation process, how-ever, the questionnaire itself was designed as a completely new tool, since no similar research regarding the structural validity the Questionnaire on Health Care Professionals' Attitudes on Accreditation of Health Care Institutions had not been previously done.
Two questionnaire structure included two blocks. Th e fi rst block included general information about the respondent and it consisted of three questions, two of which were multiple-choice, while respondents were instructed to fi ll in the blank regarding the question about their age. Th e second block consisted of 23 questions regarding the health care professionals' attitudes on the accreditation process, its impacts on the organization, planning, implementation, communication on all levels, professional affi rmation and employee satisfaction, as well as the quality of health care in the institution. Th e answers in the second part of the questionnaire were defi ned by ordinal three-step descending Likert scale (from 0-2), which expresses the degree of agreement with one of the gradients of ordinal scale (0-I agree; 1-undecided; 2-I disagree).

Legal and ethical aspects
Th e survey was anonymous in both institutions. All participants signed the Informed Consent. Th e study was approved by the ethics committees of the institutions where the research was conducted with Permission of the Ethics Committee of the Health Center Zvezdara from 30 May 2015, and Permission of the Ethics Committee of the Health Center Zemun from 17 February, 2016.

Inclusion or exclusion criteria
Th e study included: employees of both health care institutions (doctors and nurses), who voluntarily agreed to participate in the study.
Th e study did not include respondents who had multiple completed answers, or respondents who submitted questionnaires with missing answers.

Description and selection of research sites
When selecting of the institutions where the research would be conducted, it was taken into account that both institutions should have a similar structure of medical services and medical staff , and that both institutions were tertiary levels of health care. In HC-A, 25% of the total number of employees were doctors, and 75% were nurses and health care technicians, while in HC-B, 27% of the total number of employees were doctors, and 73% nurses and health care technicians.
Th e fi rst institution was HC-A, in Belgrade, Serbia, which had, prior to the research, already completed the process of accreditation in all organizational statutory and systematization segments, while the second institution HC-B, in Belgrade, Serbia, was chosen since it had not started the accreditation process yet.

Statistical method
Numerical data sets were described by the arithmetic mean as a measure of the central tendency, as well as by standard deviation measures of the variation between the data set. Data for categorical variables was described by frequency and percentage.
Analysis of the main components was used as a tool of inferential statistics for the assessment of the construct and content validity of the Questionnaire on Health Care Professionals' Attitudes on Accreditation. Th e relativity of the extracted components and the overall relativity were evaluated by the Cronbach's alpha coeffi cient. In component extraction, questions with communalities that were less than 0.5 were eliminated. Th e accepted minimum level of Kaiser-Meyer-Olkin's measure of adequacy was 0.80, with a minimum total explained variance of 0.70. Th e accepted lowest level of Cronbach's alpha coeffi cient was 0.7. Th e Mann Whitney test was used to evaluate diff erences in numerical continuous variables between diff erent groups of health care 838 Volume 6 • Number 3 • December 2019 • HOPH professionals who have/have not undergone the accreditation process. A χ2-test was used to estimate diff erences in frequency distributions by modalities of nominal variables. Statistical data processing was done in the IBM SPSS Statistics 20 package, New York, USA.

RESULTS
According to the data from 31 December 2015, At HC-A, 294 doctors and 866 nurses and health care technicians were employed. During 2015, 247,636 medical examinations were performed at HC-A, and 29,037 patients were admitted.
In the same period, 258 doctors and 700 nurses and health care technicians were employed at HC-B. 187,825 medical examinations were performed, and 21,109 patients were admitted.
Th e study involved 271 subjects from HC-A and 206 subjects from HC-B. Th e average age of the respondents in the overall sample of 477 health care professionals from both institutions was 43.25 years ± 8.89 years. Th ere was no diff erence in the age of the health care professionals surveyed between institutions (t = 0.867; df = 469.836; p = 0.386). Th e average age of HC-A subjects was 43.55 years ± 9.50 years, while the average age of HC-B subjects was 42.85 years ± 8.01 years. Th ere was no difference between institutions in the frequency distribution of surveyed health workers by gender (χ2 = 0.379; df = 1; p = 0.538). Th e frequency distribution of respondents by gender and occupation is shown in Table 1. Th ere was no diff erence between institutions in the frequency distribution of surveyed health workers by occupational category (χ2 = 0.951; df = 1; p = 0.329).

Structural validity, content validity and reliability of the Questionnaire on Health Care Professionals' Attitudes on Accreditation (QHCPAA).
Th e principal components analysis was conducted on data obtained from 477 health care professionals from both institutions. Ten valid questions were extracted from a total pool of 23 questions. Due to the adjustment of the direction of the newly obtained calibration scale, three questions were recorded by replacing the Likert scale values as follows: a) value 0 was replaced by 2, b) value 2 was replaced by 0, and Descriptive statistics on extracted questions are presented in Table 2.
Data has shown that the obtained QHCPAA consisting of ten questions has high structural validity (Kaiser-Meyer-Olkin measure of adequacy = 0.909; df = 45; χ2 = 3226.590; p = 0.000). Th e analysis of the principal components of the ten questions identifi ed three factors or components (Table 3). Th is measuring instrument has high content validity, as 78.19% of the variance of the investigated phenomenon was explained on the tested sample. Th e overall reliability of the Questionnaire was 0.916 (Table 3).
Th e fi rst factor consists of six questions: a) Th e accreditation process is an opportunity for the hospital to discover its capabilities, strengths and weaknesses; b) Aft er the accreditation process, hospitals can defi ne their goals in an easier and more realistic manner; c) Changes that occur during the preparation for the accreditation process are short-lived; d) Th e accreditation process has a signifi cant impact on hospital PR; e) Benefi ts that the accreditation process brings www.hophonline.org are unclear to me and f) Th e accreditation process has the eff ect of changing the overall concept of health care protection.
Th is factor is called the Attitude on the Positive Long-Term Impacts of Accreditation on the Planning, Implementation and Changes of the Overall Concept of Health Care.
Th e second factor addresses two issues: a) Th e accreditation process is a signifi cant opportunity for personal and professional improvement and b) Responsibilities at work signifi cantly increase post-accreditation.
Th is factor is called the Attitude on Increasing Professional Affi rmation and Improving Work Morale.
Th e third factor also consists of two questions: a) Th e accreditation process contributes to the increase in work safety of all employees and b) Th e accreditation process signifi cantly improves communication on all levels.
Th is factor is called the Attitude on Improving Communication and Safety at Work.
Th e scores on the components of the questionnaire were obtained by summing the answers' points by in each individual component, aft er which they were divided by the total number of questions that make up that particular component. Th e total score was obtained by summing the points of all ten questions.
Descriptive statistics on the scores  of individual components and the total score of health care providers' attitudes toward accreditation are presented in Table 4. By analysing the diff erences in scores between the group of health workers employed at HC-A and those employed at HC-B, it was found that employees of HC-A had 840 Volume 6 • Number 3 • December 2019 • HOPH lower scores on all components, equal to the overall score on health care professionals' attitudes on accreditation (Table 5).

DISCUSSION
Th e analysis of the frequency distribution of health workers surveyed in this research by occupational categories in both institutions has shown that 30% of the total number of health workers surveyed were doctors, while nurses and health technicians made up 70% of the surveyed population. Th e data provided is consistent with the representation of doctors in relation to nurses and health technicians in the observed hospitals.

Questions
Component Communalities 1 2 3 The accreditation process is an opportunity for the hospital to discover its capabilities, strengths and weaknesses.  By conducting a principal component analysis on the data completed by 477 employees at HC-A and HC-B, ten questions that comprised the three main components were identifi ed out of a total pool of 23 questions. It has shown that the Questionnaire has high structural or structural validity (Kaiser-Meyer-Olkin measure of adequacy = 0.909; df = 45; χ2 = 3226.590; p = 0.000), implying that it is a reliable testing instrument of employees' views on accreditation, and can be used in future research. In addition, the overall reliability of the QHCPAA was very good (Cronbach alpha = 0.916), while the reliability of its extracted components was also satisfactory ( Table 3).
Some surveys of health care professionals' attitudes on accreditation have indicated that a large number of them believe that accreditation has increased the workload and paperwork, reduced fl exibility in work, and contributed to employees' attention going more towards the implementation of the process and less towards improving the quality [14].
Th e above-mentioned data indicates the importance of educating health care professionals on accreditation before starting the procedure, as well as allowing them to learn about the experiences of colleagues who have gone through the process. In this way, they could be further motivated to actively participate in planned activities.
Alchenizan and Shaw have also come to the same conclusion. In their review, they have stated that it is necessary to inform health care professionals, especially doctors, about the potential benefi ts of accreditation before starting the process [10]. However, all the aforementioned experiences from previous studies have not been obtained through the use of content-validated instruments for measuring health care professionals' attitudes on accreditation.
On the other hand, the use of QHP-CAA in our study makes it possible to obtain reliable and valid insights into employees' attitudes about the three essential factors of accreditation, in which health care professionals should be, or already have been included.
Th e fi rst factor that stands out is called the Attitude on the Positive Long-Term Impacts of Accreditation on the Planning, Implementation and Changes of the Overall Concept of Health Care and it covers six questions: Th e accreditation process is an opportunity for the hospital to discover its capabilities, strengths and weaknesses; Aft er the accreditation process, hospitals can defi ne their goals in an easier and more realistic manner; Changes that occur during the preparation for the accreditation process are short-lived; Th e accreditation process has a signifi cant impact on hospital PR; Benefi ts that the accreditation process brings are unclear to me, and Th e accreditation process has the eff ect of changing the overall concept of health care protection.
According to research done by Verstraete and his associates, accreditation improved adherence to work procedures [14]. Furthermore, a study conducted in India among doctors, hospital directors and insurance representatives has shown that respondents had given a high degree of support to the accreditation process [15]. In addition, it is easier for accredited hospitals to better defi ne the role of their institution and the planning of services, which can consequently enable the management to organize health services more adequately [16,17].
Th e results of a study conducted by Pomeyand et al. showed that preparing for the process of accreditation itself was an opportunity for employees to think individually about the organization of work despite their previous beliefs that accreditation had no substantive point [18].
An analysis of the impact that the experiences gained during the accreditation process had on changing health care professionals' attitudes regarding accreditation showed that health care professionals employed at HC-A who had completed the accreditation had more positive views about the process than health care professionals employed at HC-B who had no such experience, in the total score as well as the the individual components scores (Table  5). Th is points to the fact that participating in the accreditation process contributes to a more positive opinion of it. However, it also shows the need to introduce a survey of employees' attitudes about accreditation as an inevitable step before deciding whether to enter into the accreditation process immediately, or to organize educational seminars that would provide employees with new information aimed at maximizing their support in the institution's accreditation, prior to the process.
Another factor that stood out from the analysis of the main components is the At-titude on Increasing Professional Affi rmation and Improving Work Morality, and this factor addresses two issues: Th e accreditation process is a signifi cant opportunity for personal and professional improvement and Responsibilities at work signifi cantly increase post-accreditation.
Th e employees of the accredited institution had a better view of the possibilities of increasing professional affi rmation through the accreditation process, as well as the improvement of work morale. Th is is important because, according to Stoelwinder, doctors believe that they are only responsible for professional work with patients and cooperation with colleagues, while the work organization of the institution in which they are employed is not within their responsibility [19]. An Australian study has found that working with colleagues is one of the factors contributing to greater motivation for participating in the accreditation process. Moreover, their interest in participating in the accreditation process is partly a result of the benefi ts they had gained from previous engagements [7].
Th e third factor that stands out is called the Attitude on Improving Communication and Safety at Work, and it also addresses two questions: Th e accreditation process contributes to the increase in work safety of all employees and Th e accreditation process significantly improves communication on all levels. We have also shown that employees in HC-A have a better view of the impact of accreditation on improving communication and safety at work.
According to the results of our study, health care professionals who had experience with accreditation also have more affi rmative views on the process. Th ey believe that accreditation has long-lasting impacts on the planning, implementation, and change of the overall concepts of health care. It is necessary to address the importance of conceptual reforms in connecting quality of care with health care costs. Th is is important, since the accreditation process itself carries considerable costs for the institution. In a study of health care professionals' economic reasoning, Vuković and Jakovljević have shown that the health care professionals 'observation about management's neglect of quality costs is the most important factor in their economic reasoning [20]. Th ey further emphasize that economic restrictions on health care that were imple-842 Volume 6 • Number 3 • December 2019 • HOPH mented in Serbia between 2010 and 2013, due to the recent economic crisis, are the reason why the attitudes of health care professionals regarding the preservation of the quality of health care have signifi cantly worsened [21]. Vuković explains the worsening reasoning in terms of greater neglect of quality costs by management in health care institutions as a disastrous consequence of economic restrictions (if implemented), and if, in order to reduce direct costs in health care institutions, the implementations of reformative, long-term, conceptual measures in the fi eld of quality management that would have lasting economic benefi ts for the institution, should be applied simultaneously [22].
According to this, it is important to emphasize that health care professionals who have had experiences with accreditation perceive the accreditation process itself as an intervention that has a positive long-term impact on planning and implementation in the health care institution. Th erefore, the lack of funds for covering the costs of accreditation (due to lower annual payments during economic restrictions by the National Health Insurance Fund and the Ministry of Health of the Republic of Serbia) poses a barrier to the process only in institutions where management teams neglect the costs of health care quality and have insuffi cient knowledge and/ or inadequately apply the concept of continuous quality improvement in the process of health service delivery. On the other hand, according to our results, health care professionals are of the opinion that such leadership not only represents a barrier to accreditation but also poses an obstacle to planning and developing the concept of permanently obtaining quality culture, as well as an obstacle to their professional affi rmation and improvement of work morale in an institution [23].
Although the health care professionals' attitudes on the accreditation process could potentially aff ect poor outcomes of the health care institutions in which they work, unfortunately, in regards to current accreditation standards, any standards that would adequately relate to the achieved levels of quality health care within the institution have not been defi ned yet [24].
Regarding the limitations of our study, we emphasize that while no instruments for measuring the health care providers' attitudes on accreditation have been validated so www.hophonline.org far, other validated instruments for measuring the health care professionals' attitudes on professional satisfaction, quality, or cost of health care quality have not been applied in our study. For the aforementioned reasons, the direct correlation of the components of the employees' attitudes on accreditation with the components that make up the content of the other validated instruments could not be made, but could be discussed indirectly based on of logical implications. On the other hand, context factors (economic restrictions, limiting the number of health care workers employed to the bare minimum, as well as accumulating administrative work for health care professionals due to layoff s of non-medical staff ) could certainly have a signifi cant impact on health care professionals' views of professional satisfaction, motivation, as well as the quality and/or cost of quality health care in health care institutions [25]. Th erefore, we consider future research to be of utmost importance. We hope that the aforementioned instruments (QH-PCAA) would be used to adequately assess the impact that accreditation, as an intervention has on changing the employees' attitudes about health care quality, professional motivation and eff ectiveness [26].

CONCLUSION
Th e Questionnaire on Health Care Professionals' Attitudes on Accreditation of Health Care Institutions used in this research has high content and structural validity and is a reliable instrument for examining the hospital health care professionals' attitudes regarding the accreditation process. Its use makes it possible to obtain a clear insight into the hospital employees' attitudes regarding the essential aspects of accreditation in a valid and reliable manner, such as attitudes about the positive longterm eff ects of accreditation on the planning, implementation and changes of the overall concept of health care, as well as enhancing professional affi rmation and improvement of work morale, communication and work safety. Experience with accreditation enables health care professionals to view this process as a reformative intervention that has a positive and long-term impact on the planning and realization of the health care institution. It is of utmost importance that the management of the health care institution starts planning the implementation of the accreditation process, and should, prior to initiating the process itself, examine employees' attitudes regarding accreditation and provide employees with timely and specifi c information, but also identify and remove potential barriers that it may produce in the institution's accreditation process.

CONFLICT OF INTEREST
Th e authors deny any potential confl icts of interest.

FINANCIAL DISCLOSURE STATEMENT
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Respected colleague,
This questionnaire is one of the instruments for a survey on the connection between ACCREDITATION and QUALITY of health care. The questionnaire is anonymous and the results will be used for scientifi c purposes only. Your consent to participate in the survey is implied,should you return the completed questionnaire. Thank you for your contribution. The accreditation process is an opportunity for the hospital to discover its capabilities, strengths and weaknesses.

2.2
After the accreditation process, hospitals can defi ne their goals in an easier and more realistic manner.

2.3
All profi les of employees are covered by the accreditation process.

2.4
The preparation for the accreditation process contributes to the quality improvement of hospital operations.

2.5
Changes that occur during the preparation for the accreditation process are short-lived.

2.6
The accreditation processhas a signifi cant impact on hospital PR.

2.7
The accreditation process signifi cantly improves the specialists'quality of work as well as patient safety.

2.8
The accreditation process signifi cantly increases workload.

2.9
The accreditation process does not bring any significant changes in regards to patient care.

2.10
Health care quality assessment is a continuous process and it's a part of daily activities.

2.11
The accreditation process increases satisfaction with the provided care in both healthcare professionals and patients.

2.12
The greatest importance of the accreditation process is in the work organization within the health care institution.

2.13
Benefi ts that the accreditation process brings are unclear to me.
2.14 Standards, criteria and guides cannot improve quality on their own.

2.15
The accreditation process signifi cantly improves communication on all levels.

2.16
The accreditation process has the eff ect of changing the overall concept of health care protection.

2.17
The accreditation process is a signifi cant opportunity for personal and professional improvement.

2.18
Teamwork is not well received despite the accreditation process.

2.20
There is a lack of education based on the employees' needs.

2.21
Patient safety increases signifi cantly after the accreditation process.

2.22
Prior to starting the procedure, healthcare professionals do not know much about the accreditation process.

2.23
The accreditation process contributes to the increase in work safety of all employees.
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