International Healthcare Accreditation: an Analysis of Clinical Quality and Patient Experience in the UAE Subashnie Devkaran, FACHE, MScHCM, BSc (Physiotherapy), CPHQ, Edinburgh Business School, Heriot-Watt University Submitted for the degree of Doctor of Philosophy April 2014 The copyright in this thesis is owned by the author. Any quotation from the thesis or use of any of the information contained in it must acknowledge this thesis as the source of the quotation or information. I ABSTRACT A mixed method research design was used to answer the question; ‘does accreditation have an impact on hospital quality, clinical measures and patient experience?’ The thesis contains three study components: 1) A case study determining the predictors of patient experience; 2) a cross-sectional study examining the relationship of hospital accreditation and patient experience and 3) A four year time series analysis of the impact of accreditation on hospital quality using 27 quality measures. A case study analysis of patient experience, using a piloted, validated and reliable survey tool, was conducted in Al Noor Hospital. The survey was administered via face- to-face interviews to 391 patients. Patient demographic variables, stay characteristics and patient experience constructs were tested against five patient experience outcome measures using regression analysis. The predictors of positive patient experience were the patient demographics (age, nationality, and health status), hospital stay characteristics (length of stay and hospital treatment outcome) and patient experience constructs (care from nurses, care from doctors, cleanliness, pain management and quality of food). Recommendations were made on how hospital managers can improve patient experience using these modifiable factors. The cross-sectional study found that accredited hospitals had significantly higher inpatient experience scores than non-accredited hospitals. The hospital level variables, other than patient volume, had no correlations with patient experience. The interrupted time series analysis demonstrated that although accreditation improved the quality performance of the hospital with a residual benefit of 20 percentage points above the baseline level, this improvement was not sustained over the 3-year accreditation cycle. The accreditation life cycle theory was developed as an explanatory framework for the pattern of performance during the accreditation cycle. This theory was consequently supported by empirical evidence. Recommendations were made for improvement of the accreditation process. The Life Cycle Model and time series analysis were proposed as strategic tools for healthcare managers to recognise and prevent the negative trends of the accreditation life cycle in order to sustain improvements gained from accreditation. II The findings of the three research components were triangulated to form a theory on the impact of accreditation on clinical quality measures and patient experience. This thesis is important from a research perspective, as healthcare accreditation, although commonly used to improve quality, is still under researched and under theorised. This is the first investigation of accreditation to use interrupted time series analysis, the first analysis on patient experience and hospital accreditation and also the first study on patient experience in the Middle East. Thus it adds to the evidence base of accreditation and patient experience but also has policy and management implications. III DEDICATION To my mother who provided me with a strong foundation on which to rise and constant support throughout my life. To my children, Nikira and Nikyle, who are my inspiration and truly the wind beneath my wings. IV ACKNOWLEDGEMENTS “Intelligence plus character-that is the goal of true education.” -Martin Luther King Jr. This doctoral thesis has stimulated the developement of these fundamentals, which would not have been possible without the invaluable support and assistance of several individuals. Firstly, I am fervently grateful to my supervisor, mentor and respected friend, Professor Patrick O’Farrell, whose discussion, wisdom, critique, precious insight and professional guidance imbued me to pursue rigor, critical thinking and the evolution of innovative ideas and perspectives. His inspiring and encouraging disposition guided me to a deeper understanding of the knowledge base. I am truly blessed to have met and worked with such a phenomenal individual. I have relished this journey because of our partnership. He has touched my life and changed it for the better by personifying the adage, “The task of the modern educator is not to cut down jungles, but to irrigate deserts.”- C.S. Lewis. Secondly, I am truly indebted to my wonderful family and feel fortunate to have them in my life. I am grateful to my amazing mother, Sabitha, whose constant support never wavered. Her calm reassurance, valuable insights and positivity gave me the strength to continue till the end. This thesis would not have been possible without her. She is the best mother anyone could wish for. My lovely children, Nikira and Nikyle, were absolute angels. Their patience and willingness for me to succeed motivated me. They always put things in perspective, made me laugh, inspired me and made me feel like the luckiest mom in the world. I love you all! I thank my understanding husband, Jaishen, who supported me from start to finish and came to appreciate the learning that goes into a doctoral degree. I am grateful to my father, Roland, who always believed that I could achieve this and provided constant support. I am appreciative of the leadership at Al Noor Hospital, Airport Road and the Quality Department for their support and encouragement throughout the thesis, specifically, Dr. Peter Hill, Randy Arcangel, Bryan Abrero, Dr. Sara Alom and Dr. Taha Ibrahim. I would also like to express my sincere gratitude to all the Examiners (chiefly Professor Alex Scott and Professor Ciarán O'Boyle) and the Research Committee. Their assistance and support is acknowledged and deeply appreciated. Subashnie Devkaran V DECLARATION STATEMENT ACADEMIC REGISTRY Research Thesis Submission Name: SUBASHNIE DEVKARAN School/PGI: EDINBURGH BUSINESS SCHOOL Version: (i.e. First, FINAL Degree Sought (Award PhDoctorD of Philosophy (Ph.D) Resubmission, Final) and Subject area) Declaration In accordance with the appropriate regulations I hereby submit my thesis and I declare that: 1) the thesis embodies the results of my own work and has been composed by myself 2) where appropriate, I have made acknowledgement of the work of others and have made reference to work carried out in collaboration with other persons 3) the thesis is the correct version of the thesis for submission and is the same version as any electronic versions submitted*. 4) my thesis for the award referred to, deposited in the Heriot-Watt University Library, should be made available for loan or photocopying and be available via the Institutional Repository, subject to such conditions as the Librarian may require 5) I understand that as a student of the University I am required to abide by the Regulations of the University and to conform to its discipline. * Please note that it is the responsibility of the candidate to ensure that the correct version of the thesis is submitted. TH Signature of Date: 2027TH F EBAPRILRUAR 2014Y 201 4 Candidate: Submission Submitted By (name in capitals): SUBASHNIE DEVKARAN Signature of Individual Submitting: TH Date Submitted: 2027TH FEB APRILRUAR 2014Y 201 4 For Completion in the Student Service Centre (SSC) Received in the SSC by (name in capitals): Method of Submission (Handed in to SSC; posted through internal/external mail): E-thesis Submitted (mandatory for final theses) Signature: Date: Please note this form should bound into the submitted thesis. Updated February 2008, November 2008, February 2009, January 2011 Please note this form should bound into the submitted thesis. Updated February 2008, November 2008, February 2009, JanuaryVI 201 1 TABLE OF CONTENTS ABSTRACT ........................................................................................................................... II DEDICATION ...................................................................................................................... IV ACKNOWLEDGEMENTS ........................................................................................................ V DECLARATION STATEMENT ................................................................................................ VI TABLE OF CONTENTS ......................................................................................................... VII LIST OF TABLES .................................................................................................................. XII LIST OF FIGURES ............................................................................................................... XIV LIST OF EQUATIONS ......................................................................................................... XIV INTRODUCTION ................................................................................................................... 1 1 CHAPTER ONE: THE LITERATURE REVIEW AND LITERATURE SYNTHESIS ....................... 4 1.1 THE LITERATURE REVIEW ................................................................................................... 4 1.1.1 Introduction ............................................................................................................