The Impact of the CBAHI Accreditation on Patient Outcomes: Evidence from Two Hospitals in Eastern Saudi Arabia

The Impact of the CBAHI Accreditation on Patient Outcomes: Evidence from Two Hospitals in Eastern Saudi Arabia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of the CBAHI Accreditation on Patient Outcomes: Evidence from Two Hospitals in Eastern Saudi Arabia Afnan Aljaffary, Kawthar Alhassan, Noor Almumen, Sara Albahrani, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8076168/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background The Central Board for Accreditation of Healthcare Institutions (CBAHI) was introduced in Saudi Arabia to enhance healthcare quality and patient safety. However, empirical evidence on its effectiveness in improving patient outcomes is scarce. Objectives To evaluate the impact of the CBAHI accreditation on hospital length of stay (LOS) and 30-day readmission rates, assess seasonal variation in these outcomes, and explore healthcare workers’ perceptions of accreditation in different hospital settings. Methods A pre-post quantitative analysis was conducted using (Key Performance Indicators) KPIs data from a private hospital from 2019 to 2022, covering periods before, after, and one year post-CBAHI accreditation. Additionally, a cross-sectional survey was administered to 149 healthcare providers at a private and quasi-governmental hospital at the Eastern Province of Saudi Arabia to determine staff perceptions of the impact of the accreditation on improving healthcare delivery. The English version of the questionniare is provided in Appendix 1. Results A statistically significant reduction in LOS was observed after accreditation (p < .001), though the 30-day readmission rates increased slightly (p = .027). No significant seasonal variation was found. Survey results revealed mixed perceptions of accreditation, with higher engagement and perceived benefits reported by semi-government hospital staff and those with bachelor’s degrees. Conclusion The CBAHI accreditation appears to improve LOS but has a limited impact on readmission rates. Healthcare providers’ perceptions vary according to hospital type and involvement in the accreditation process. These insights may guide future improvements in accreditation practices and implementation strategies. accreditation patient outcomes readmission length of stay healthcare quality Saudi Arabia Figures Figure 1 Figure 2 Figure 3 Figure 4 Background International Context: Accreditation and Patient Safety In 1999, the Institute of Medicine’s report, To Err Is Human , marked a turning point in global healthcare by revealing the alarming extent of medical errors in hospitals and other care settings. The report estimated that tens of thousands of deaths each year in the United States were attributable to preventable errors and urged healthcare systems worldwide to decrease these errors by 50% within five years (Kohn et al., 2000; Devers et al., 2004). It recommended improvements through three interrelated mechanisms: professionalism, market forces, and regulations. Regulatory mechanisms such as government-mandated standards have been identified as primary tools for ensuring safe and high-quality care (Devers et al., 2004). Healthcare accreditation is a widely adopted regulatory tool. Accreditation is defined as an external evaluation process conducted by an independent or governmental agency to assess healthcare organizations’ compliance with defined standards (Hussein et al., 2021). These standards typically span multiple domains (i.e., structure, processes, and outcomes) to ensure that services are delivered safely, efficiently, and consistently. Accreditation programs vary in scope and enforcement; some are voluntary and performed by professional bodies, while others are mandated by health ministries or government agencies (El-Jardali et al., 2008). Despite its widespread adoption, its effectiveness remains a topic of debate in the global literature. While many scholars emphasize its potential to enhance care quality, improve safety, and streamline clinical and administrative processes, others highlight its limitations, including additional bureaucracy, increased documentation, and a lack of clear correlation with improved clinical outcomes (Brubakk et al., 2015; Greenfield & Braithwaite, 2008). Healthcare professionals’ perception and engagement are critical factors influencing the effectiveness of accreditation. Studies suggest that its implementation is more successful when healthcare staff view accreditation as a tool for improvement rather than a bureaucratic requirement. Conversely, when staff perceive accreditation as burdensome or separate from direct patient care, it may lead to disengagement, increased work stress, and superficial compliance (Alkhenizan & Shaw, 2012; Paccioni & Sicotte, 2008; Van et al., 2023). Furthermore, the global evidence base shows that the success of accreditation programs not only depends on the content of the standards but also on contextual factors such as leadership support, readiness for change, interprofessional collaboration, and the integration of quality initiatives into routine practice (Greenfield et al., 2011; Alhawajreh et al., 2025). However, few studies have comprehensively examined accreditation using the full Donabedian model (structure, process, and outcome). Moreover, only a limited number of studies have directly assessed its relationship with measurable clinical improvements (Al-Alawya & Obaida, 2021). This highlights the ongoing need for rigorous empirical studies to evaluate the real-world impact of accreditation, particularly in different healthcare systems and economic contexts. National Context: Accreditation in Saudi Arabia Healthcare reform has been a major focus of Saudi Arabia’s national development agenda, particularly in Vision 2030. Since the 1970s, the Saudi government has invested heavily in expanding the healthcare infrastructure, increasing hospital capacity, and advancing total quality management initiatives (Almasabi, 2013; Almasabi & Thomas, 2017). These efforts have substantially increased the number of public and private healthcare institutions and the demand for systems that ensure the quality and safety of care. Concurrently, the Central Board for Accreditation of Healthcare Institutions (CBAHI) was established in 2005 as Saudi Arabia’s official accreditation body. The CBAHI was initially launched as a voluntary program but became mandatory in 2014 for all public and private healthcare providers operating in the nation (Althumairi et al., 2022). By 2015, healthcare institutions were required to meet the CBAHI standards and obtain accreditation to remain operational (Aboshaiqah et al., 2016). Despite the rapid adoption of the accreditation standards, the literature evaluating the effectiveness of the CBAHI is still emerging. Some studies have raised concerns regarding whether the CBAHI has achieved its intended outcomes. For example, Alotaibi (2023) noted that accreditation in Saudi Arabia is still in the early implementation phase, with insufficient evidence supporting its association with improved patient care and clinical outcomes. Similarly, Almasabi and Thomas (2017) expressed concerns about whether the CBAHI efficiently uses resources and meaningfully improves the quality of care in the Saudi context. Accreditation and Patient Outcomes Globally, clinical outcomes such as hospital length of stay (LOS) and 30-day readmission rates are recognized as important indicators of healthcare quality. These metrics reflect the effectiveness of hospital processes, adequacy of discharge planning, and continuity of care following hospitalization (Lee, 2019). Accreditation is assumed to improve these outcomes by standardizing care, reducing variability, and enhancing inter-professional collaboration. Several international studies have reported an association between accreditation and LOS reduction. Bergholt et al. (2022), Falstie-Jensen et al. (2015, 2018), and de Deus Leite et al. (2019) reported that hospitals undergoing accreditation experienced shorter inpatient stays, which was attributed to better care coordination and the adoption of clinical pathways. In contrast, other studies found no significant impact or unfavorable outcomes. Lee (2021) found no difference in LOS in accredited hospitals and Wardhani et al. (2019) reported longer LOS and higher mortality rates in accredited facilities, thus challenging the assumption that accreditation always improves outcomes. Evidence for 30-day readmission is similarly mixed. While Lam et al. (2018) found that accredited hospitals had significantly lower readmission rates, other studies, found no statistically significant association between accreditation and readmissions, although no adverse effects were observed (Falstie-Jensen et al., 2015; Falstie-Jensen et al.,2018; Bergholt et al.,2022). In Saudi Arabia, there is limited but growing literature assessing the impact of accreditation on patient outcomes. For instance, Shaikh et al. (2018) found no statistically significant differences in LOS or 48-hour ICU readmission rates before and after accreditation in a tertiary care hospital. Conversely, Almasabi and Thomas (2017) observed statistically significant improvements in LOS and infection rates in three public hospitals, although they found no change in mortality. Alqarni et al. (2021) found no substantial changes in safety or efficiency outcomes following accreditation at Makkah Hospitals. However, a broader cross-sectional study by Al-Sughayir et al. (2025) suggested that CBAHI accreditation is associated with reduced LOS and medication-related morbidity. Additionally, Alsakkak et al. (2017) evaluated CBAHI implementation in primary healthcare centers, noting process and infrastructure improvements, although they did not assess clinical outcomes. Despite these contributions, the literature still lacks pre-post accreditation studies that directly evaluate the impact of the CBAHI on LOS and 30-day readmission rates in diverse hospital settings. It is essential to address this gap to understand the real-world effectiveness of accreditation in the Saudi healthcare system. Healthcare Providers’ Perceptions on Accreditation and Patients’ Outcomes Healthcare providers’ perceptions are crucial to understand the influence of accreditation on practice. If frontline staff perceive accreditation as a meaningful driver of quality, their engagement is likely to increase, thereby facilitating implementation and sustainability. Conversely, if accreditation is perceived as a burden or merely an administrative exercise, its effectiveness may be compromised (Alkhenizan & Shaw, 2012; Brubakk et al., 2015). In the Saudi context, Almasabi and Thomas (2017) conducted a qualitative survey in which many providers indicated that the CBAHI focused excessively on documentation rather than on patient-centered care. Similarly, a study in Kuwait found that staff experienced considerable challenges, including workload increases and pressure during accreditation cycles (Katoue et al., 2021). These findings suggest that while accreditation aims to improve quality, its implementation may have unintended consequences if the staff feels disconnected or unsupported. However, some studies have reported positive perceptions. Saeda (2012) found that nurses perceived improvements in care quality and organizational culture during and after accreditation. Key enablers of positive perceptions include leadership support, staff training, reward systems, and the visible benefits of accreditation. Algahtani (2017) found that healthcare professionals (nurses, physicians, and allied health staff) viewed accreditation as a catalyst for improved service delivery. Despite these insights, there remains a significant gap in the literature regarding healthcare providers’ perceptions of CBAHI accreditation, particularly in mixed public-private hospital settings. Few studies have explored how perceptions vary across roles (e.g., nurses versus physicians), facility types, or accreditation cycles. Understanding these perspectives is vital because healthcare providers are not just passive recipients of accreditation, but are also active agents in its success or failure. Their attitudes can influence compliance, drive improvement initiatives, and ultimately affect the quality of patient care. Significance of the Current Study Given the variability in outcomes and provider experiences, this study sought to address critical knowledge gaps by assessing the impact of the CBAHI accreditation on clinical outcomes, specifically hospital length of stay and 30-day readmission rates, in a private facility (Dr. Sulaiman Al-Habib Hospital). Additionally, the present study examined seasonal variations in these outcomes and explored healthcare workers’ perceptions of how accreditation affects healthcare delivery from two different types of hospitals in Khobar, Saudi Arabia: a semi-government facility (King Fahd University Hospital) and a private facility (Dr. Sulaiman Al-Habib Hospital). More specifically, to explore the potential impact of the structure and organization of health settings on health workers’ perceptions on the impact of accreditation on quality and patient outcomes. By employing a pre-post design and integrating qualitative insights, this study aimed to provide practical, context-specific evidence to inform accreditation policies and implementation strategies in the KSA and beyond. Methods Research Design The present study was conducted in two phases. Phase 1 was a quantitative retrospective study using secondary data obtained from the hospitals’ key performance indicators (KPIs). The dependent variables were patient clinical outcomes (LOS and 30-day readmission rate). The independent variables were the pre- and post-accreditation periods ( in months) and seasons of the year. Phase 2 employed a cross-sectional study design using a structured, self-administered questionnaire distributed to healthcare providers. Study Setting The study was conducted at two hospitals in Saudi Arabia’s Eastern Province (Khobar): King Fahd University Hospital (KFUH), a semi-government hospital, and Dr. Sulaiman Alhabib Hospital, a private hospital. Participants In Phase 1, we included the KPIs of patients who had been treated at Dr. Sulaiman Alhabib Hospital in Khobar, one year before the intervention (CBAHI accreditation) and one year after the intervention. We included patients who were readmitted within 30 days and excluded those who were readmitted after 30 days. The exposed population comprised patients admitted after the intervention (accreditation) and the non-exposed population comprised patients admitted before the accreditation. In Phase 2, 149 healthcare providers from Dr. Sulaiman Alhabib Hospital and KFUH were recruited to participate and complete the study questionnaire. Data collection methods Instruments We used a paper-based questionnaire containing 10 demographic questions, four domains consisting of 24 questions on a Likert scale, and three open-ended questions. Data Source Primary Data About 149 healthcare providers were recruited to participate in the study using convenience sampling at both Dr. Sulaiman Alhabib Hospital and KFUH, with a response rate of 60%. The content validity of the questionnaire was assessed by six experts, four of whom responded to the email and shared their comments on clarity and ability to answer questions. Questionnaire items were modified to ensure clarity and relativeness. Secondary Data We used KPIs from the quality department of Dr. Sulaiman Al-Habib Hospital for the LOS and 30-day readmission rate in the periods before and one year after the intervention (CBAHI accreditation) for 2019, 2020, 2021, and 2022 (accredited by the CBAHI on October 27, 2020). Bias This study has several limitations. First, the presence of prior Joint Commission International (JCI) accreditation at one of the hospitals may have influenced the outcomes observed after the CBAHI accreditation, introducing potential bias. Second, the study was limited to only two hospitals located in the Eastern Province of Saudi Arabia, which may have affected the generalizability of the findings. Finally, the sample size was relatively small. Out of 200 distributed questionnaires, only 149 responses were received, which may have limited the statistical power of the analysis. Analysis Data were analyzed using SPSS. Demographic data were summarized using frequency and percentage for each score, as well as the mean and standard deviation. One-way analysis of variance (ANOVA) and t-tests were used to determine differences in demographic variables between groups, and the Pearson correlation coefficient was calculated. Statistical significance was set at 5%. Results The outcomes of readmission within 30 days and LOS were analyzed before, after, and one year following the CBAHI accreditation. Results from the primary data (questionnaire) included participants’ characteristics, descriptive statistics of the questionnaire dimensions, and a bivariate analysis of the study variables. Phase 1 Results Average Length of Stay There was a statistically significant difference (f = 27.114, p = .000) in the average LOS and period of accreditation (before, after, and one year after). The highest average LOS occurred before the accreditation process (mean = 3.1, SD = .3), followed by after the accreditation period (mean = 2.8, SD = .1). The lowest mean was one year after the accreditation (mean = 2.6, SD = .0; Table 1 ). The graphical presentation (box and whisker plots) shows the differences between the averages of these three periods (Fig. 1 ). There was no significant relationship between the average LOS and seasons (f = 1.459, p = .245). The average LOS was the highest in spring (mean = 2.9, SD = .3) and lowest in autumn (mean = 2.6, SD = .1; Table 1 ). Figure 2 shows the difference in the average LOS among seasons. Table 1 Comparison between average length of stay and 30-day readmission rate with periods before, after, and one year after the accreditation and seasons. Variables Average Length of Stay Mean (SD) = 2.8020 (.26130) 30 days readmission rate (%) Mean (SD) = 4.337 (.6499) Mean (SD) Test ( p -value) Mean (SD) Test ( p -value) Period of accreditation Before After One year after 3.1 (.3) 2.8 (.1) 2.6 (.0) 27.114 (.000) 4.0 (.6) 4.4 (.4) 4.6 (.7) 3.972 (.027) Season Summer Autumn Spring Winter 2.85(.3) 2.6 (.1) 2.87(.3) 2.8 (.3) 1.459 (.245) 4.1 (.5) 4.3 (.6) 4.5 (.8) 4.5 (.7) .794 (.505) 30-day Readmission Rate (%) There was a significant relationship between the period of accreditation (before, after, and one year after) and the 30-day readmission rate (f = 3.972, p = .027). The highest mean for the 30-day readmission rate occurred one year after the accreditation process (mean = 4.6, SD = .7), followed by after the accreditation period (mean = 4.4, SD = .4; Fig. 3 ). The 30-day readmission rate had no significant relationship with seasons (f = .794, p = .505). Hospitals had the highest readmission rates in spring (mean = 4.510, SD = .8) and the lowest in summer (mean = 4.1, SD = .5; Fig. 4 ). Phase 2 Results Participants’ Characteristics Table 2 shows the demographic characteristics; 50% of the participants were aged between 30 and 40 years. The majority of the healthcare workers who responded were female (57.3%) and Saudi Arabians (57.3%). The majority of the participants had five years of experience (46%). Most participants had a bachelor’s degree (61.3%). Most participants were nurses (38%). Approximately 44% worked in patient care units, 77.3% had direct contact with patients, and 70% were involved in the accreditation process. Approximately 65.3% of participants worked in private hospitals. Table 2 Descriptive statistics of participants demographics Variables Groups/ highest mean Quality results Staff involvement Benefits of accreditation Accreditation Results Test ( p -value) Type of hospital . Private . Public . Semi-government f = 3.835 p = .024 Qualifications . High School . Diploma . Bachelor . Postgraduate f = 6.851 p = .000 f = 7.920 p = .000 Involvement in accreditation process . Yes . No t = 2.449 p = .016 Working unit . Multiple units . Patient care units . Management . Supporting services . Other f = 3.114 p = .017 Abbreviations: n,sample size; SD ,Standard Deviation ; t, t-test value; f, ANOVA test value Descriptive Statistics of Questionnaire Dimensions A total of 149 participants answered the questionnaire, with a 60% response rate. The benefits of the accreditation domain had the highest mean (mean = 36.75, SD = 10.663), followed by staff involvement (mean = 19.85, SD = 5.254), and quality results (mean = 19.91, SD = 3.279). The lowest mean was reported for the accreditation results domain (mean = 18.69, SD = 5.026; Table 2 ). Bivariate Analysis of the Study Variables In the quality results domain, which contained five questions about improvements in the quality of services provided by different departments in the hospital (Table 3 ), there was a statistically significant difference in the domain and type of hospital (f = 3.835, p = .024). Participants in semi-government hospitals had a higher mean score (mean = 22.3, SD = 2.5) than those in public and private hospitals (Table 4 ). Regarding the staff involvement domain, which included specific items about involvement in the accreditation process and participation in the action plan as a response to the recommendations of the CBAHI (Table 3 ), there was a statistically significant difference between this domain and participants’ qualifications (f = 6.851, p = .000), where participants with bachelor’s degrees reported the highest mean in this domain compared to the other groups (mean = 20.4, SD = 5.1). Additionally, involvement in the accreditation process was significantly associated with the staff involvement domain ( t = 2.449, p = .016). Participants involved in accreditation reported the highest mean in this domain (mean = 20.6, SD = 5.1) compared to their counterparts (Table 4 ). The benefits of accreditation domain (Table 4 ) contained questions about the value added by the CBAHI and showed significant differences in participants’ qualifications (f = 7.920, p = .000): participants with a bachelor’s degree had the highest mean (mean = 37.7, SD = 10.1) compared to other groups (Table 4 ). In the accreditation results, which included items about the improvement in patient clinical outcomes (length of stay, readmission, etc.) after CBAHI accreditation (Table 3 ), there were significant differences between this domain and participants’ working units (f = 3.114, p = .017); participants working in patient care units reported a higher mean score (mean = 18.7, SD = 4.8) than those working in management units (mean = 18.1, SD = 4.1; Table 4 ). Table 3 Pearson’s correlation between variables. Variables Mean (SD) Correlation ( p -value) Quality results Staff involvement Benefits of accreditation Accreditation Results Total score Quality results 19.9 (3.3) 1 .314** (.000) .267** (.001) .505** (.000) .549** (.000) Staff involvement 19.9 (5.3) .314** (.000) 1 .845** (.000) .224** (.006) .870** (.000) Benefits of accreditation 36.8 (10.7) .267** (.001) .845** (.000) 1 .256** (.002) .914** (.000) Accreditation results 18.7 (5.0) .505** (.000) .224** (.006) .256** (.002) 1 .564** (.000) Total score 95.0 (19.3) .549** (.000) .870** (.000) .914** (.000) .564** (.000) 1 Table 4 Response rates on the items of different domains in the questionnaire. Domain/ item Percent % Quality Result Strongly Disagree Disagree Neutral Agree Strongly Agree 1. Over the past 3 years, the hospital has shown steady, measurable improvements in the quality of customer Satisfaction. 2.0 1.3 11.3 57.3 28.0 2. Over the past 3 years, the hospital has shown steady, measurable improvements in the quality of services provided by the administration (finance, human resources, etc). 1.3 1.3 20.7 46.7 26.0 3. Over the past 3 years, the hospital has shown steady, measurable improvements in the quality of care provided to patients (e.g. medical, surgical, obstetric and pediatric patients). 1.3 4.7 16.0 50.0 28.0 4. Over the past 3 years, the hospital has shown steady, measurable improvements in the quality of services provided by clinical support departments such as laboratory, pharmacy, and radiology. .7 .7 15.3 51.3 29.3 5. Over the past 3 years, the hospital has maintained a high-quality of patients health services despite financial constraints .7 3.3 28.7 40.0 26.7 Staff involvement Strongly Disagree Disagree Neutral Agree Strongly Agree 6. During the preparation for the last CBAHI accreditation survey, important changes were implemented at the hospital for example improvements in patients’ health outcomes. 0 5.3 20.0 47.3 26.7 7. I participated in the implementation of these Changes. 2.7 4.0 24.0 41.3 22.7 8. The recommendation from the first CBAHI cycle was useful to me. 1.3 4.7 20.7 44.7 44.7 9. The recommendation from the first CBAHI cycle were used to improve work at the hospital .7 .7 18.7 18.7 25.3 10. I was part of the action plan that was initiated as a response to the recommendations from the first CBAHI cycle. 4.0 4.0 25.3 34.0 25.3 Benefits of accreditation Strongly Disagree Disagree Neutral Agree Strongly Agree 11. CBAHI Accreditation enables the improvement of patient Care. 3.3 2.0 10.0 48.7 32.0 12. CBAHI Accreditation enables the motivation of staff and encourages team work and collaboration. 1.3 3.3 15.3 46.7 28.7 13. CBAHI Accreditation enables the development of values shared by all professionals at the hospital. 1.3 2.7 14.0 48.7 28.0 14. CBAHI Accreditation enables the hospital to better use its internal resources (e.g. finances, people, time, and equipment). 2.0 4.0 19.3 42.7 28.0 15. CBAHI Accreditation enables the hospital to better respond to the populations needs. .7 6.7 18.0 43.3 24.7 16. CBAHI Accreditation enables the hospital to better respond to its partners (other hospitals, diverse hospitals, private clinics, etc). 0 4.0 19.3 46.7 24.0 17. CBAHI Accreditation contributes to the development of collaboration with partners in the health care system. 0 4.7 21.3 44.0 24.0 18. CBAHI Accreditation is a valuable tool for the hospital to implement changes. .7 1.3 16.7 50.7 22.7 19. The hospital’s participation in CBAHI accreditation enables it to be more responsive when changes are to be implemented. 2.0 0 18.7 43.3 30.7 Accreditation Results Strongly Disagree Disagree Neutral Agree Strongly Agree 20. The mortality rate had decreased after gaining CBAHI accreditation. 1.3 6.0 30.7 36.0 23.3 21. The infection rate had declined after gaining CBAHI accreditation. 1.3 4.0 21.3 46.7 23.3 22. The LOS had decreased after gaining CBAHI accreditation. .7 3.3 30.0 45.3 16.7 23. The readmission within 30 days of discharge had decreased after gaining CBAHI accreditation. 2.0 5.3 28.7 40.7 20.0 24. Overall Patients' health outcomes have been improved after gaining CBAHI accreditation. 1.3 6.7 19.3 42.7 26.0 Correlation All domains had a significant relationship with the CBAHI accreditation. We found a strong positive correlation between staff involvement and the benefits of accreditation, which means that the higher the involvement of the staff in the accreditation process, the higher the possibility that they report positive perceptions of the benefits of accreditation in their hospitals ( r = 0.845, p = 0.000). Other domains showed weak correlations with each other (Table 4 ). The correlation between staff involvement and accreditation results was the lowest ( r = 0.224, p < 0.006). Discussion This section discusses the key findings of the study in relation to its three primary objectives contextualized within the existing body of literature and considering the implications for healthcare policy and practice in Saudi Arabia. Impact of CBAHI Accreditation on Patient Outcomes The first objective aimed to assess the effect of CBAHI accreditation on two critical patient-related health outcomes: average length of stay (LOS) and 30-day readmission rates at Dr. Sulaiman Al-Habib Hospital in Khobar. The findings indicated that while CBAHI accreditation was associated with a reduction in LOS, no statistically significant change was observed in 30-day readmission rates. This finding supports the argument that accreditation may enhance organizational efficiency through streamlined processes and standardized care pathways, leading to faster patient turnover (Falstie-Jensen et al., 2015; Bergholt et al., 2022). Similar results have been reported in European settings, where accreditation contributed to improved care coordination and reduced LOS, but had a limited or inconsistent impact on readmission or mortality (Falstie-Jensen et al., 2015; Lam et al., 2018). These findings suggest that while accreditation may optimize internal processes, multiple factors that extend beyond institutional boundaries can influence readmissions, including post-discharge care and patient socioeconomic factors (Lee, 2021). Seasonal Variation in Patient Outcomes The second objective addressed the seasonal variation in the LOS and 30-day readmission rates. The analysis revealed that both metrics peaked during the summer months. This aligns with previous literature indicating that healthcare utilization patterns fluctuate seasonally due to changes in disease prevalence, staffing levels, and climate-related factors (Hospitals et al., 2000; Wichmann et al., 2011). For example, high ambient temperatures have been associated with increased hospital admissions and prolonged recovery times, particularly among patients with chronic conditions or psychiatric disorders. These findings underscore the importance of incorporating environmental and operational variables in hospital performance assessments. Strategic workforce planning and resource allocation during peak seasons can mitigate these fluctuations and improve patient outcomes. Healthcare Providers’ Perceptions of Accreditation The third objective explored healthcare providers’ perceptions of accreditation and its influence on quality improvement. The results demonstrated that staff from semi-government hospitals reported more positive perceptions of the impact of accreditation than those from private hospitals. This finding is consistent with that of Al-Khabbaz (2017) who reported similar trends in public sector facilities in Kuwait, potentially due to stronger institutional support for quality improvement initiatives. However, contrary evidence exists in the literature. Althumairi et al. (2022) reported a higher compliance with safety standards in private Saudi hospitals. This discrepancy may stem from differences in the sample size, geographic distribution, or hospital type. Additionally, our study revealed that providers with bachelor’s degrees were more likely to participate and recognize the benefits of accreditation, which aligns with findings by Abolfotouh et al. (2014). This may reflect the differences in training emphasis and exposure to quality assurance principles during academic preparation. Furthermore, participants working in direct patient care roles (e.g., inpatient units) were more likely to perceive accreditation as beneficial to clinical outcomes. This is consistent with Hijazi et al. (2018), who reported a stronger endorsement of accreditation among frontline staff in Jordanian hospitals. In contrast, paraclinical and administrative staff were less engaged, which may reflect a perceived disconnect between their roles and quality improvement initiatives. Senior leadership support has been highlighted as a critical factor for success. Most respondents agreed that hospital executives were actively involved in strategic planning and quality enhancement, echoing findings from El-Jardali et al. (2014). However, a subset of participants expressed skepticism, citing limited managerial involvement, insufficient staff training, and accreditation as a paperwork-driven rather than patient-centered process (Kakemam & Rajabi, 2020; Greenfield et al., 2011). Implications and Future Directions These findings reinforce the idea that while accreditation has the potential to improve operational efficiency and foster a culture of quality, its impact on patient outcomes is contingent on context-specific variables, including organizational culture, staff engagement, and leadership support. The mixed perceptions among healthcare providers further underscore the need for inclusive training programs and transparent communication regarding the purposes and benefits of accreditation. A notable gap in the literature, particularly in the Saudi context, is the limited number of robust pre-post studies examining both clinical outcomes and staff perspectives. Future research should adopt a longitudinal design across multiple hospital types and regions to better evaluate the sustained impact of the CBAHI accreditation. Incorporating patient-reported outcomes and integrating accreditation with broader health system reforms can provide a holistic assessment of accreditation’s value. Conclusion In summary, this study assessed the impact of the CBAHI accreditation on LOS and 30-day readmission rates by comparing patient health outcomes before and after the first cycle of the CBAHI accreditation in Dr. Sulaman Alhabib Hospital (Khobar), comparing the LOS and 30-day readmission rates among different seasons of the year in the same hospital, and exploring healthcare workers’ perspectives on the impact of the CBAHI accreditation on improving healthcare delivery in both KFUH and Dr. Sulaiman Alhabib Hospital. This study demonstrates that the CBAHI accreditation is a sufficient tool to improve LOS but not 30-day readmission rates at Dr. Sulaiman Alhabib Hospital. Furthermore, season had no effect on the LOS or 30-day readmission rates at this hospital. Finally, some healthcare providers reported that the CBAHI improved the quality of healthcare services, whereas others perceived no effect. Our results reject the first null hypothesis that the CBAHI accreditation does not shorten the LOS. However, we accept the second hypothesis, which states that the CBAHI accreditation does not reduce the 30-day readmission rate. The CBAHI was not successful in reducing readmission rates, or the hospital did not meet the CBAHI standards. The third null hypothesis, showing that the season had no effect on LOS or 30-day readmission rates, was accepted. Some healthcare providers did not notice the positive impact of the CBAHI accreditation. This may support the fourth null hypothesis, which states that the CBAHI accreditation does not improve healthcare delivery from the healthcare provider’s perspective. This study has some limitations. The JCI accreditation was conducted before the CBAHI, which may introduce some bias. This study included only two hospitals in the Eastern province of Saudi Arabia. In addition, the sample size was small; only 149 out of 200 individuals completed the survey. Future studies should include different types of hospitals in different regions of the KSA to obtain a more comprehensive picture of the impact of the CBAHI accreditation, increase the period before and after accreditation, and include more than two patient clinical outcomes. Abbreviations CBAHI the Central Board for Accreditation of Healthcare Institutions LOS length of stay, KSA:Kingdom of Saudi Arabia KPIs Key Performance Indicators ANOVA Analysis of Variance JCI Joint Commission International Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board (IRB) at Imam Abdurrahman bin Faisal University through an expedited review on Wednesday, January 18, 2023 (IRB number: IRB-UGS-2023-03-028). All procedures involving human subjects adhered to the guidelines specified in the Declaration of Helsinki. Patient identities in the data collected in Phase 1 were anonymized, and information was accessible only to the study researchers. In Phase 2, an informed consent was signed by the healthcare providers prior filling out the questionnaire. Consent for publication NA Availability of data and materials The data of this manuscript is avaliable upon request. Competing Interests NA Funding The authors declare that no funding was received for this study. Authors' contributions A.W, S.A, and N.A contributed in selecting the proper methodology, data collection, interpretation the findings, and drafting the research manuscript. A.A, and F.A contributed in the conceptualization, data interpretation and finalizing the final version of the manuscript. L.A contributed in making throrough review of the final version of the manuscript. Acknowledgements NA References Alkhenizan A, Shaw C. The attitude of health care professionals towards accreditation: a systematic review of the literature. J Fam Community Med 2012;19(2):74–80. doi:10.4103/22308229.98282 Alsakkak MA, Alwahabi SA, Alsalhi HM, Shugdar MA. Outcome of the first Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) primary health care accreditation cycle in Saudi Arabia. Saudi Med J 2017;38(11):1132–6. doi:10.15537/smj.2017.11.20760 Alqarni A, Kattan W, Alzahrani K, Elkhashab A. The impact of CBAHI accreditation on efficiency rate and patient safety: Makkah experience, KSA. Am J Clin Med Res 2021;9(2):48–52. doi:10.12691/ajcmr-9-2-3 Bergholt MD, von Plessen C, Johnsen SP, Hibbert P, Braithwaite J, Valentin JB, et al. Accreditation and clinical outcomes: shorter length of stay after first-time hospital accreditation in the Faroe Islands. Int J Qual Health Care 2022;34(2):mzac015. doi:10.1093/intqhc/mzac015 Brubakk G, Vist GE, Bukholm G, Barach P, Tjomsland O. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res 2015;15:280. doi:10.1186/s12913-015-0933-x Devers KJ, Pham HH, Liu JL. Responding to the IOM report "To Err Is Human": A health policy perspective. N Engl J Med 2004;351(25):2492–7. de Deus Leite C, Pereira TC, Freitas MP, Tinôco NLW, Menezes RVLV, Andrade MQS, et al. Effect of hospital accreditation process on outcomes of patients with acute coronary syndrome. Int J Cardiovasc Sci 2019;32(6):607–14. doi:10.5935/2359-4802.20190034 El-Jardali F, Jamal D, Dimassi H, Ammar W, Tchaghchaghian V. The impact of hospital accreditation on quality of care: perception of Lebanese nurses. Int J Qual Health Care 2008;20(5):363–71. doi:10.1093/intqhc/mzn023 Falstie-Jensen AM, Nørgaard M, Hollnagel E, Larsson H, Johnsen SP. Is compliance with hospital accreditation associated with length of stay and acute readmission? A Danish nationwide population-based study. Int J Qual Health Care 2015;27(6):451–8. doi:10.1093/intqhc/mzv070 Falstie-Jensen AM, Bogh SB, Johnsen SP. Consecutive cycles of hospital accreditation: persistent low compliance associated with higher mortality and longer length of stay. Int J Qual Health Care 2018;30(5):382–9. doi:10.1093/intqhc/mzy037 Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. Int J Qual Health Care 2008;20(3):172–83. doi:10.1093/intqhc/mzn013 Greenfield D, Pawsey M, Hinchcliff R, Moldovan M, Braithwaite J. The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact. BMC Health Serv Res 2011;11:336. doi:10.1186/1472-6963-11-336 Hussein A, Hays R, Saad AMP. A systematic overview of accreditation impacts on healthcare. Int J Health Care Qual Assur 2021;34(2):mzac015. doi:10.1093/intqhc/mzac015 Katoue T, Al-Jedai A, Al-Taweel D. Staff experiences of accreditation in Kuwaiti primary care centres. Saudi Med J 2021;42(1). Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington (DC): National Academy Press; 2000. Lam, M.B., Figueroa, J.F., Feyman, Y., Reimold, K.E., Orav, E.J. and Jha, A.K.,. Association between patient outcomes and accreditation in US hospitals: observational study. Bmj, 2018;363. Lee BY, Chun YJ, Lee YH. Structure, function, and impact of hospital accreditation in South Korea. J Hosp Manag Health Policy 2021;5:31. Paccioni A, Sicotte C, Champagne F. Accreditation: a cultural control strategy. Int J Health Care Qual Assur 2008;21(2):146–58. doi:10.1108/09526860810859043 Saeda AM. Nurses’ perceptions of quality improvement during accreditation in Saudi Arabia. Asian Nurs Res 2012;6(2):59–67. doi:10.1016/j.anr.2012.07.001 Shaikh ZM, Al-Omari A, Ahmed A. The impact of CBAHI accreditation on critical care unit outcome quality measures: a case study. Int J Health Sci Res 2018;8(7):394–407. Van Vliet EJ, Soethout J, Churruca K, Braithwaite J, Luxford K, Stewart J, et al. International approaches for implementing accreditation programmes in different healthcare facilities: a comparative case study in Australia, Botswana, Denmark, and Jordan. International Journal for Quality in Health Care. 2023; 35(2):1–12. doi:10.1093/intqhc/mzad026. Wardhani V, van Dijk JP, Utarini A. Hospital accreditation status in Indonesia: associations with performance indicators. BMC Health Serv Res 2019;19:372. doi:10.1186/s12913-019-4187-x Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":165448,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eComparison of Average Length of Stay (LOS) Before, After, and One Year After the CBAHI Accreditation\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8076168/v1/70a605408f5e98157fa16855.png"},{"id":99223338,"identity":"21ca13db-bf5a-488c-ad16-53d39373fd47","added_by":"auto","created_at":"2025-12-30 09:59:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":153647,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eComparison of Average Length of Stay (LOS) Across Seasons\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8076168/v1/aac174b05c6b59318ffa6dc2.png"},{"id":99223336,"identity":"c8e59e81-5dbb-43d6-a7ee-c39835e3b5e9","added_by":"auto","created_at":"2025-12-30 09:59:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":168631,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eComparison of 30-Day Readmission Rate Before, After, and One Year After the CBAHI Accreditation\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8076168/v1/92bf5415523974ccc450db92.png"},{"id":99318858,"identity":"b427e19e-34ee-4f42-9616-441e3d687504","added_by":"auto","created_at":"2025-12-31 16:35:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":157984,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eComparison of 30-Day Readmission Rate Across Seasons\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8076168/v1/80bf6254e39c75c17cdfa48d.png"},{"id":100356226,"identity":"3989dbfd-3774-4c57-af55-80a2432ca5ac","added_by":"auto","created_at":"2026-01-16 06:57:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1955556,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8076168/v1/96d1c7f3-3fc8-4d8f-b293-a2740edb82cc.pdf"},{"id":99223332,"identity":"6aaef9b2-6406-4920-91ef-50d08f5b5ab9","added_by":"auto","created_at":"2025-12-30 09:59:55","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":69759,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixQuestionniare.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8076168/v1/326bd9bf4ba35764b93dbf5a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of the CBAHI Accreditation on Patient Outcomes: Evidence from Two Hospitals in Eastern Saudi Arabia","fulltext":[{"header":"Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eInternational Context: Accreditation and Patient Safety\u003c/h2\u003e \u003cp\u003eIn 1999, the Institute of Medicine\u0026rsquo;s report, \u003cem\u003eTo Err Is Human\u003c/em\u003e, marked a turning point in global healthcare by revealing the alarming extent of medical errors in hospitals and other care settings. The report estimated that tens of thousands of deaths each year in the United States were attributable to preventable errors and urged healthcare systems worldwide to decrease these errors by 50% within five years (Kohn et al., 2000; Devers et al., 2004). It recommended improvements through three interrelated mechanisms: professionalism, market forces, and regulations. Regulatory mechanisms such as government-mandated standards have been identified as primary tools for ensuring safe and high-quality care (Devers et al., 2004).\u003c/p\u003e \u003cp\u003eHealthcare accreditation is a widely adopted regulatory tool. Accreditation is defined as an external evaluation process conducted by an independent or governmental agency to assess healthcare organizations\u0026rsquo; compliance with defined standards (Hussein et al., 2021). These standards typically span multiple domains (i.e., structure, processes, and outcomes) to ensure that services are delivered safely, efficiently, and consistently. Accreditation programs vary in scope and enforcement; some are voluntary and performed by professional bodies, while others are mandated by health ministries or government agencies (El-Jardali et al., 2008).\u003c/p\u003e \u003cp\u003eDespite its widespread adoption, its effectiveness remains a topic of debate in the global literature. While many scholars emphasize its potential to enhance care quality, improve safety, and streamline clinical and administrative processes, others highlight its limitations, including additional bureaucracy, increased documentation, and a lack of clear correlation with improved clinical outcomes (Brubakk et al., 2015; Greenfield \u0026amp; Braithwaite, 2008).\u003c/p\u003e \u003cp\u003eHealthcare professionals\u0026rsquo; perception and engagement are critical factors influencing the effectiveness of accreditation. Studies suggest that its implementation is more successful when healthcare staff view accreditation as a tool for improvement rather than a bureaucratic requirement. Conversely, when staff perceive accreditation as burdensome or separate from direct patient care, it may lead to disengagement, increased work stress, and superficial compliance (Alkhenizan \u0026amp; Shaw, 2012; Paccioni \u0026amp; Sicotte, 2008; Van et al., 2023).\u003c/p\u003e \u003cp\u003eFurthermore, the global evidence base shows that the success of accreditation programs not only depends on the content of the standards but also on contextual factors such as leadership support, readiness for change, interprofessional collaboration, and the integration of quality initiatives into routine practice (Greenfield et al., 2011; Alhawajreh et al., 2025).\u003c/p\u003e \u003cp\u003eHowever, few studies have comprehensively examined accreditation using the full Donabedian model (structure, process, and outcome). Moreover, only a limited number of studies have directly assessed its relationship with measurable clinical improvements (Al-Alawya \u0026amp; Obaida, 2021). This highlights the ongoing need for rigorous empirical studies to evaluate the real-world impact of accreditation, particularly in different healthcare systems and economic contexts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eNational Context: Accreditation in Saudi Arabia\u003c/h2\u003e \u003cp\u003eHealthcare reform has been a major focus of Saudi Arabia\u0026rsquo;s national development agenda, particularly in Vision 2030. Since the 1970s, the Saudi government has invested heavily in expanding the healthcare infrastructure, increasing hospital capacity, and advancing total quality management initiatives (Almasabi, 2013; Almasabi \u0026amp; Thomas, 2017). These efforts have substantially increased the number of public and private healthcare institutions and the demand for systems that ensure the quality and safety of care.\u003c/p\u003e \u003cp\u003eConcurrently, the Central Board for Accreditation of Healthcare Institutions (CBAHI) was established in 2005 as Saudi Arabia\u0026rsquo;s official accreditation body. The CBAHI was initially launched as a voluntary program but became mandatory in 2014 for all public and private healthcare providers operating in the nation (Althumairi et al., 2022). By 2015, healthcare institutions were required to meet the CBAHI standards and obtain accreditation to remain operational (Aboshaiqah et al., 2016).\u003c/p\u003e \u003cp\u003eDespite the rapid adoption of the accreditation standards, the literature evaluating the effectiveness of the CBAHI is still emerging. Some studies have raised concerns regarding whether the CBAHI has achieved its intended outcomes. For example, Alotaibi (2023) noted that accreditation in Saudi Arabia is still in the early implementation phase, with insufficient evidence supporting its association with improved patient care and clinical outcomes. Similarly, Almasabi and Thomas (2017) expressed concerns about whether the CBAHI efficiently uses resources and meaningfully improves the quality of care in the Saudi context.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAccreditation and Patient Outcomes\u003c/h3\u003e\n\u003cp\u003eGlobally, clinical outcomes such as hospital \u003cb\u003elength of stay (LOS)\u003c/b\u003e and \u003cb\u003e30-day readmission rates\u003c/b\u003e are recognized as important indicators of healthcare quality. These metrics reflect the effectiveness of hospital processes, adequacy of discharge planning, and continuity of care following hospitalization (Lee, 2019). Accreditation is assumed to improve these outcomes by standardizing care, reducing variability, and enhancing inter-professional collaboration.\u003c/p\u003e \u003cp\u003eSeveral international studies have reported an association between accreditation and LOS reduction. Bergholt et al. (2022), Falstie-Jensen et al. (2015, 2018), and de Deus Leite et al. (2019) reported that hospitals undergoing accreditation experienced shorter inpatient stays, which was attributed to better care coordination and the adoption of clinical pathways. In contrast, other studies found no significant impact or unfavorable outcomes. Lee (2021) found no difference in LOS in accredited hospitals and Wardhani et al. (2019) reported longer LOS and higher mortality rates in accredited facilities, thus challenging the assumption that accreditation always improves outcomes.\u003c/p\u003e \u003cp\u003eEvidence for 30-day readmission is similarly mixed. While Lam et al. (2018) found that accredited hospitals had significantly lower readmission rates, other studies, found no statistically significant association between accreditation and readmissions, although no adverse effects were observed (Falstie-Jensen et al., 2015; Falstie-Jensen et al.,2018; Bergholt et al.,2022).\u003c/p\u003e \u003cp\u003eIn Saudi Arabia, there is limited but growing literature assessing the impact of accreditation on patient outcomes. For instance, Shaikh et al. (2018) found no statistically significant differences in LOS or 48-hour ICU readmission rates before and after accreditation in a tertiary care hospital. Conversely, Almasabi and Thomas (2017) observed statistically significant improvements in LOS and infection rates in three public hospitals, although they found no change in mortality. Alqarni et al. (2021) found no substantial changes in safety or efficiency outcomes following accreditation at Makkah Hospitals. However, a broader cross-sectional study by Al-Sughayir et al. (2025) suggested that CBAHI accreditation is associated with reduced LOS and medication-related morbidity. Additionally, Alsakkak et al. (2017) evaluated CBAHI implementation in primary healthcare centers, noting process and infrastructure improvements, although they did not assess clinical outcomes.\u003c/p\u003e \u003cp\u003eDespite these contributions, the literature still lacks pre-post accreditation studies that directly evaluate the impact of the CBAHI on LOS and 30-day readmission rates in diverse hospital settings. It is essential to address this gap to understand the real-world effectiveness of accreditation in the Saudi healthcare system.\u003c/p\u003e\n\u003ch3\u003eHealthcare Providers’ Perceptions on Accreditation and Patients’ Outcomes\u003c/h3\u003e\n\u003cp\u003eHealthcare providers\u0026rsquo; perceptions are crucial to understand the influence of accreditation on practice. If frontline staff perceive accreditation as a meaningful driver of quality, their engagement is likely to increase, thereby facilitating implementation and sustainability. Conversely, if accreditation is perceived as a burden or merely an administrative exercise, its effectiveness may be compromised (Alkhenizan \u0026amp; Shaw, 2012; Brubakk et al., 2015).\u003c/p\u003e \u003cp\u003eIn the Saudi context, Almasabi and Thomas (2017) conducted a qualitative survey in which many providers indicated that the CBAHI focused excessively on documentation rather than on patient-centered care. Similarly, a study in Kuwait found that staff experienced considerable challenges, including workload increases and pressure during accreditation cycles (Katoue et al., 2021). These findings suggest that while accreditation aims to improve quality, its implementation may have unintended consequences if the staff feels disconnected or unsupported.\u003c/p\u003e \u003cp\u003eHowever, some studies have reported positive perceptions. Saeda (2012) found that nurses perceived improvements in care quality and organizational culture during and after accreditation. Key enablers of positive perceptions include leadership support, staff training, reward systems, and the visible benefits of accreditation. Algahtani (2017) found that healthcare professionals (nurses, physicians, and allied health staff) viewed accreditation as a catalyst for improved service delivery.\u003c/p\u003e \u003cp\u003eDespite these insights, there remains a significant gap in the literature regarding healthcare providers\u0026rsquo; perceptions of CBAHI accreditation, particularly in mixed public-private hospital settings. Few studies have explored how perceptions vary across roles (e.g., nurses versus physicians), facility types, or accreditation cycles. Understanding these perspectives is vital because healthcare providers are not just passive recipients of accreditation, but are also active agents in its success or failure. Their attitudes can influence compliance, drive improvement initiatives, and ultimately affect the quality of patient care.\u003c/p\u003e\n\u003ch3\u003eSignificance of the Current Study\u003c/h3\u003e\n\u003cp\u003eGiven the variability in outcomes and provider experiences, this study sought to address critical knowledge gaps by assessing the impact of the CBAHI accreditation on clinical outcomes, specifically hospital length of stay and 30-day readmission rates, in a private facility (Dr. Sulaiman Al-Habib Hospital). Additionally, the present study examined seasonal variations in these outcomes and explored healthcare workers\u0026rsquo; perceptions of how accreditation affects healthcare delivery from two different types of hospitals in Khobar, Saudi Arabia: a semi-government facility (King Fahd University Hospital) and a private facility (Dr. Sulaiman Al-Habib Hospital). More specifically, to explore the potential impact of the structure and organization of health settings on health workers\u0026rsquo; perceptions on the impact of accreditation on quality and patient outcomes. By employing a pre-post design and integrating qualitative insights, this study aimed to provide practical, context-specific evidence to inform accreditation policies and implementation strategies in the KSA and beyond.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResearch Design\u003c/h2\u003e \u003cp\u003eThe present study was conducted in two phases. Phase 1 was a quantitative retrospective study using secondary data obtained from the hospitals\u0026rsquo; key performance indicators (KPIs). The dependent variables were patient clinical outcomes (LOS and 30-day readmission rate). The independent variables were the pre- and post-accreditation periods ( in months) and seasons of the year. Phase 2 employed a cross-sectional study design using a structured, self-administered questionnaire distributed to healthcare providers.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted at two hospitals in Saudi Arabia\u0026rsquo;s Eastern Province (Khobar): King Fahd University Hospital (KFUH), a semi-government hospital, and Dr. Sulaiman Alhabib Hospital, a private hospital.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eIn Phase 1, we included the KPIs of patients who had been treated at Dr. Sulaiman Alhabib Hospital in Khobar, one year before the intervention (CBAHI accreditation) and one year after the intervention. We included patients who were readmitted within 30 days and excluded those who were readmitted after 30 days. The exposed population comprised patients admitted after the intervention (accreditation) and the non-exposed population comprised patients admitted before the accreditation. In Phase 2, 149 healthcare providers from Dr. Sulaiman Alhabib Hospital and KFUH were recruited to participate and complete the study questionnaire.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData collection methods\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eInstruments\u003c/h2\u003e \u003cp\u003eWe used a paper-based questionnaire containing 10 demographic questions, four domains consisting of 24 questions on a Likert scale, and three open-ended questions.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData Source\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003ePrimary Data\u003c/h2\u003e \u003cp\u003eAbout 149 healthcare providers were recruited to participate in the study using convenience sampling at both Dr. Sulaiman Alhabib Hospital and KFUH, with a response rate of 60%. The content validity of the questionnaire was assessed by six experts, four of whom responded to the email and shared their comments on clarity and ability to answer questions. Questionnaire items were modified to ensure clarity and relativeness.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSecondary Data\u003c/h2\u003e \u003cp\u003eWe used KPIs from the quality department of Dr. Sulaiman Al-Habib Hospital for the LOS and 30-day readmission rate in the periods before and one year after the intervention (CBAHI accreditation) for 2019, 2020, 2021, and 2022 (accredited by the CBAHI on October 27, 2020).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eBias\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the presence of prior Joint Commission International (JCI) accreditation at one of the hospitals may have influenced the outcomes observed after the CBAHI accreditation, introducing potential bias. Second, the study was limited to only two hospitals located in the Eastern Province of Saudi Arabia, which may have affected the generalizability of the findings. Finally, the sample size was relatively small. Out of 200 distributed questionnaires, only 149 responses were received, which may have limited the statistical power of the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS. Demographic data were summarized using frequency and percentage for each score, as well as the mean and standard deviation. One-way analysis of variance (ANOVA) and t-tests were used to determine differences in demographic variables between groups, and the Pearson correlation coefficient was calculated. Statistical significance was set at 5%.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe outcomes of readmission within 30 days and LOS were analyzed before, after, and one year following the CBAHI accreditation. Results from the primary data (questionnaire) included participants\u0026rsquo; characteristics, descriptive statistics of the questionnaire dimensions, and a bivariate analysis of the study variables.\u003c/p\u003e\n\u003ch2\u003ePhase 1 Results\u003c/h2\u003e\n\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n \u003ch2\u003eAverage Length of Stay\u003c/h2\u003e\n \u003cp\u003eThere was a statistically significant difference (f\u0026thinsp;=\u0026thinsp;27.114, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.000) in the average LOS and period of accreditation (before, after, and one year after). The highest average LOS occurred before the accreditation process (mean\u0026thinsp;=\u0026thinsp;3.1, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.3), followed by after the accreditation period (mean\u0026thinsp;=\u0026thinsp;2.8, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.1). The lowest mean was one year after the accreditation (mean\u0026thinsp;=\u0026thinsp;2.6, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.0; Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The graphical presentation (box and whisker plots) shows the differences between the averages of these three periods (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). There was no significant relationship between the average LOS and seasons (f\u0026thinsp;=\u0026thinsp;1.459, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.245). The average LOS was the highest in spring (mean\u0026thinsp;=\u0026thinsp;2.9, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.3) and lowest in autumn (mean\u0026thinsp;=\u0026thinsp;2.6, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.1; Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the difference in the average LOS among seasons.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison between average length of stay and 30-day readmission rate with periods before, after, and one year after the accreditation and seasons.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAverage Length of Stay\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u0026thinsp;=\u0026thinsp;2.8020 (.26130)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e30 days readmission rate (%)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u0026thinsp;=\u0026thinsp;4.337 (.6499)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTest (\u003cem\u003ep\u003c/em\u003e-value)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTest (\u003cem\u003ep\u003c/em\u003e-value)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePeriod of accreditation\u003c/p\u003e\n \u003cp\u003eBefore\u003c/p\u003e\n \u003cp\u003eAfter\u003c/p\u003e\n \u003cp\u003eOne year after\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.1 (.3)\u003c/p\u003e\n \u003cp\u003e2.8 (.1)\u003c/p\u003e\n \u003cp\u003e2.6 (.0)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27.114 (.000)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.0 (.6)\u003c/p\u003e\n \u003cp\u003e4.4 (.4)\u003c/p\u003e\n \u003cp\u003e4.6 (.7)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.972 (.027)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeason\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSummer\u003c/p\u003e\n \u003cp\u003eAutumn\u003c/p\u003e\n \u003cp\u003eSpring\u003c/p\u003e\n \u003cp\u003eWinter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.85(.3)\u003c/p\u003e\n \u003cp\u003e2.6 (.1)\u003c/p\u003e\n \u003cp\u003e2.87(.3)\u003c/p\u003e\n \u003cp\u003e2.8 (.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e1.459 (.245)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.1 (.5)\u003c/p\u003e\n \u003cp\u003e4.3 (.6)\u003c/p\u003e\n \u003cp\u003e4.5 (.8)\u003c/p\u003e\n \u003cp\u003e4.5 (.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e.794 (.505)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003e30-day Readmission Rate (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThere was a significant relationship between the period of accreditation (before, after, and one year after) and the 30-day readmission rate (f\u0026thinsp;=\u0026thinsp;3.972, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.027). The highest mean for the 30-day readmission rate occurred one year after the accreditation process (mean\u0026thinsp;=\u0026thinsp;4.6, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.7), followed by after the accreditation period (mean\u0026thinsp;=\u0026thinsp;4.4, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.4; Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The 30-day readmission rate had no significant relationship with seasons (f\u0026thinsp;=\u0026thinsp;.794, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.505). Hospitals had the highest readmission rates in spring (mean\u0026thinsp;=\u0026thinsp;4.510, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.8) and the lowest in summer (mean\u0026thinsp;=\u0026thinsp;4.1, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.5; Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003ePhase 2 Results\u003c/h2\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003eParticipants\u0026rsquo; Characteristics\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the demographic characteristics; 50% of the participants were aged between 30 and 40 years. The majority of the healthcare workers who responded were female (57.3%) and Saudi Arabians (57.3%). The majority of the participants had five years of experience (46%). Most participants had a bachelor\u0026rsquo;s degree (61.3%). Most participants were nurses (38%). Approximately 44% worked in patient care units, 77.3% had direct contact with patients, and 70% were involved in the accreditation process. Approximately 65.3% of participants worked in private hospitals.\u0026nbsp;\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDescriptive statistics of participants demographics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroups/ highest mean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuality results\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStaff involvement\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBenefits of accreditation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAccreditation Results\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTest\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003ep\u003c/em\u003e-value)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e. Private\u003c/p\u003e\n \u003cp\u003e. Public\u003c/p\u003e\n \u003cp\u003e. \u003cstrong\u003eSemi-government\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ef\u0026thinsp;=\u0026thinsp;3.835\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQualifications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e. High School\u003c/p\u003e\n \u003cp\u003e. Diploma\u003c/p\u003e\n \u003cp\u003e. \u003cstrong\u003eBachelor\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e. Postgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ef\u0026thinsp;=\u0026thinsp;6.851\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ef\u0026thinsp;=\u0026thinsp;7.920\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInvolvement in accreditation process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e. \u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e. No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003et\u0026thinsp;=\u0026thinsp;2.449\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorking unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e. Multiple units\u003c/p\u003e\n \u003cp\u003e. \u003cstrong\u003ePatient care units\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e. Management\u003c/p\u003e\n \u003cp\u003e. Supporting services\u003c/p\u003e\n \u003cp\u003e. Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ef\u0026thinsp;=\u0026thinsp;3.114\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eAbbreviations: n,sample size; SD ,Standard Deviation ; t, t-test value; f, ANOVA test value\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003eDescriptive Statistics of Questionnaire Dimensions\u003c/h2\u003e\n \u003cp\u003eA total of 149 participants answered the questionnaire, with a 60% response rate. The benefits of the accreditation domain had the highest mean (mean\u0026thinsp;=\u0026thinsp;36.75, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10.663), followed by staff involvement (mean\u0026thinsp;=\u0026thinsp;19.85, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.254), and quality results (mean\u0026thinsp;=\u0026thinsp;19.91, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.279). The lowest mean was reported for the accreditation results domain (mean\u0026thinsp;=\u0026thinsp;18.69, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.026; Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n \u003ch2\u003eBivariate Analysis of the Study Variables\u003c/h2\u003e\n \u003cp\u003eIn the quality results domain, which contained five questions about improvements in the quality of services provided by different departments in the hospital (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), there was a statistically significant difference in the domain and type of hospital (f\u0026thinsp;=\u0026thinsp;3.835, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.024). Participants in semi-government hospitals had a higher mean score (mean\u0026thinsp;=\u0026thinsp;22.3, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.5) than those in public and private hospitals (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Regarding the staff involvement domain, which included specific items about involvement in the accreditation process and participation in the action plan as a response to the recommendations of the CBAHI (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), there was a statistically significant difference between this domain and participants\u0026rsquo; qualifications (f\u0026thinsp;=\u0026thinsp;6.851, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.000), where participants with bachelor\u0026rsquo;s degrees reported the highest mean in this domain compared to the other groups (mean\u0026thinsp;=\u0026thinsp;20.4, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.1). Additionally, involvement in the accreditation process was significantly associated with the staff involvement domain (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.449, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.016). Participants involved in accreditation reported the highest mean in this domain (mean\u0026thinsp;=\u0026thinsp;20.6, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.1) compared to their counterparts (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). The benefits of accreditation domain (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) contained questions about the value added by the CBAHI and showed significant differences in participants\u0026rsquo; qualifications (f\u0026thinsp;=\u0026thinsp;7.920, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.000): participants with a bachelor\u0026rsquo;s degree had the highest mean (mean\u0026thinsp;=\u0026thinsp;37.7, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10.1) compared to other groups (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). In the accreditation results, which included items about the improvement in patient clinical outcomes (length of stay, readmission, etc.) after CBAHI accreditation (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), there were significant differences between this domain and participants\u0026rsquo; working units (f\u0026thinsp;=\u0026thinsp;3.114, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.017); participants working in patient care units reported a higher mean score (mean\u0026thinsp;=\u0026thinsp;18.7, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.8) than those working in management units (mean\u0026thinsp;=\u0026thinsp;18.1, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.1; Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s correlation between variables.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003eCorrelation (\u003cem\u003ep\u003c/em\u003e-value)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality results\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff involvement\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBenefits of accreditation\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccreditation Results\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal score\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality results\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.9 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.314** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.267** (.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.505** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.549** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff involvement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.9 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.314** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.845** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.224** (.006)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.870** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBenefits of accreditation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36.8 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.267** (.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.845** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.256** (.002)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.914** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccreditation results\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.7 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.505** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.224** (.006)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.256** (.002)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.564** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e95.0 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.549** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.870** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.914** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.564** (.000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eResponse rates on the items of different domains in the questionnaire.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"6\" align=\"left\"\u003e\n \u003cp\u003eDomain/ item\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Percent %\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality Result\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Disagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. Over the past 3 years, the hospital has shown steady, measurable improvements in the quality of customer Satisfaction.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Over the past 3 years, the hospital has shown steady, measurable improvements in the quality of services provided by the administration (finance, human resources, etc).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3. Over the past 3 years, the hospital has shown steady, measurable improvements in the quality of care provided to patients (e.g. medical, surgical, obstetric and pediatric patients).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4. Over the past 3 years, the hospital has shown steady, measurable improvements in the quality of services provided by clinical support departments such as laboratory, pharmacy, and radiology.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5. Over the past 3 years, the hospital has maintained a high-quality of patients health services despite financial constraints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff involvement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Disagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6. During the preparation for the last CBAHI accreditation survey, important changes were implemented at the hospital for example improvements in patients\u0026rsquo; health outcomes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7. I participated in the implementation of these Changes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8. The recommendation from the first CBAHI cycle was useful to me.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9. The recommendation from the first CBAHI cycle were used to improve work at the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10. I was part of the action plan that was initiated as a response to the recommendations from the first CBAHI cycle.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBenefits of accreditation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Disagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11. CBAHI Accreditation enables the improvement of patient Care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12. CBAHI Accreditation enables the motivation of staff and encourages team work and collaboration.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13. CBAHI Accreditation enables the development of values shared by all professionals at the hospital.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14. CBAHI Accreditation enables the hospital to better use its internal resources (e.g. finances, people, time, and equipment).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15. CBAHI Accreditation enables the hospital to better respond to the populations needs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16. CBAHI Accreditation enables the hospital to better respond to its partners (other hospitals, diverse hospitals, private clinics, etc).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17. CBAHI Accreditation contributes to the development of collaboration with partners in the health care system.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18. CBAHI Accreditation is a valuable tool for the hospital to implement changes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19. The hospital\u0026rsquo;s participation in CBAHI accreditation enables it to be more responsive when changes are to be implemented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccreditation Results\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Disagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20. The mortality rate had decreased after gaining CBAHI accreditation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21. The infection rate had declined after gaining\u003c/p\u003e\n \u003cp\u003eCBAHI accreditation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22. The LOS had decreased after gaining CBAHI accreditation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23. The readmission within 30 days of discharge had decreased after gaining CBAHI accreditation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24. Overall Patients\u0026apos; health outcomes have been improved after gaining CBAHI accreditation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003eCorrelation\u003c/h2\u003e\n \u003cp\u003eAll domains had a significant relationship with the CBAHI accreditation. We found a strong positive correlation between staff involvement and the benefits of accreditation, which means that the higher the involvement of the staff in the accreditation process, the higher the possibility that they report positive perceptions of the benefits of accreditation in their hospitals (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.845, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000). Other domains showed weak correlations with each other (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). The correlation between staff involvement and accreditation results was the lowest (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.224, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.006).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis section discusses the key findings of the study in relation to its three primary objectives contextualized within the existing body of literature and considering the implications for healthcare policy and practice in Saudi Arabia.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eImpact of CBAHI Accreditation on Patient Outcomes\u003c/h2\u003e \u003cp\u003eThe first objective aimed to assess the effect of CBAHI accreditation on two critical patient-related health outcomes: average length of stay (LOS) and 30-day readmission rates at Dr. Sulaiman Al-Habib Hospital in Khobar. The findings indicated that while CBAHI accreditation was associated with a reduction in LOS, no statistically significant change was observed in 30-day readmission rates. This finding supports the argument that accreditation may enhance organizational efficiency through streamlined processes and standardized care pathways, leading to faster patient turnover (Falstie-Jensen et al., 2015; Bergholt et al., 2022).\u003c/p\u003e \u003cp\u003eSimilar results have been reported in European settings, where accreditation contributed to improved care coordination and reduced LOS, but had a limited or inconsistent impact on readmission or mortality (Falstie-Jensen et al., 2015; Lam et al., 2018). These findings suggest that while accreditation may optimize internal processes, multiple factors that extend beyond institutional boundaries can influence readmissions, including post-discharge care and patient socioeconomic factors (Lee, 2021).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eSeasonal Variation in Patient Outcomes\u003c/h2\u003e \u003cp\u003eThe second objective addressed the seasonal variation in the LOS and 30-day readmission rates. The analysis revealed that both metrics peaked during the summer months. This aligns with previous literature indicating that healthcare utilization patterns fluctuate seasonally due to changes in disease prevalence, staffing levels, and climate-related factors (Hospitals et al., 2000; Wichmann et al., 2011). For example, high ambient temperatures have been associated with increased hospital admissions and prolonged recovery times, particularly among patients with chronic conditions or psychiatric disorders.\u003c/p\u003e \u003cp\u003eThese findings underscore the importance of incorporating environmental and operational variables in hospital performance assessments. Strategic workforce planning and resource allocation during peak seasons can mitigate these fluctuations and improve patient outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare Providers\u0026rsquo; Perceptions of Accreditation\u003c/h2\u003e \u003cp\u003eThe third objective explored healthcare providers\u0026rsquo; perceptions of accreditation and its influence on quality improvement. The results demonstrated that staff from semi-government hospitals reported more positive perceptions of the impact of accreditation than those from private hospitals. This finding is consistent with that of Al-Khabbaz (2017) who reported similar trends in public sector facilities in Kuwait, potentially due to stronger institutional support for quality improvement initiatives.\u003c/p\u003e \u003cp\u003eHowever, contrary evidence exists in the literature. Althumairi et al. (2022) reported a higher compliance with safety standards in private Saudi hospitals. This discrepancy may stem from differences in the sample size, geographic distribution, or hospital type. Additionally, our study revealed that providers with bachelor\u0026rsquo;s degrees were more likely to participate and recognize the benefits of accreditation, which aligns with findings by Abolfotouh et al. (2014). This may reflect the differences in training emphasis and exposure to quality assurance principles during academic preparation.\u003c/p\u003e \u003cp\u003eFurthermore, participants working in direct patient care roles (e.g., inpatient units) were more likely to perceive accreditation as beneficial to clinical outcomes. This is consistent with Hijazi et al. (2018), who reported a stronger endorsement of accreditation among frontline staff in Jordanian hospitals. In contrast, paraclinical and administrative staff were less engaged, which may reflect a perceived disconnect between their roles and quality improvement initiatives.\u003c/p\u003e \u003cp\u003eSenior leadership support has been highlighted as a critical factor for success. Most respondents agreed that hospital executives were actively involved in strategic planning and quality enhancement, echoing findings from El-Jardali et al. (2014). However, a subset of participants expressed skepticism, citing limited managerial involvement, insufficient staff training, and accreditation as a paperwork-driven rather than patient-centered process (Kakemam \u0026amp; Rajabi, 2020; Greenfield et al., 2011).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImplications and Future Directions\u003c/h3\u003e\n\u003cp\u003eThese findings reinforce the idea that while accreditation has the potential to improve operational efficiency and foster a culture of quality, its impact on patient outcomes is contingent on context-specific variables, including organizational culture, staff engagement, and leadership support. The mixed perceptions among healthcare providers further underscore the need for inclusive training programs and transparent communication regarding the purposes and benefits of accreditation.\u003c/p\u003e \u003cp\u003eA notable gap in the literature, particularly in the Saudi context, is the limited number of robust pre-post studies examining both clinical outcomes and staff perspectives. Future research should adopt a longitudinal design across multiple hospital types and regions to better evaluate the sustained impact of the CBAHI accreditation. Incorporating patient-reported outcomes and integrating accreditation with broader health system reforms can provide a holistic assessment of accreditation\u0026rsquo;s value.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, this study assessed the impact of the CBAHI accreditation on LOS and 30-day readmission rates by comparing patient health outcomes before and after the first cycle of the CBAHI accreditation in Dr. Sulaman Alhabib Hospital (Khobar), comparing the LOS and 30-day readmission rates among different seasons of the year in the same hospital, and exploring healthcare workers\u0026rsquo; perspectives on the impact of the CBAHI accreditation on improving healthcare delivery in both KFUH and Dr. Sulaiman Alhabib Hospital. This study demonstrates that the CBAHI accreditation is a sufficient tool to improve LOS but not 30-day readmission rates at Dr. Sulaiman Alhabib Hospital. Furthermore, season had no effect on the LOS or 30-day readmission rates at this hospital. Finally, some healthcare providers reported that the CBAHI improved the quality of healthcare services, whereas others perceived no effect.\u003c/p\u003e \u003cp\u003eOur results reject the first null hypothesis that the CBAHI accreditation does not shorten the LOS. However, we accept the second hypothesis, which states that the CBAHI accreditation does not reduce the 30-day readmission rate. The CBAHI was not successful in reducing readmission rates, or the hospital did not meet the CBAHI standards. The third null hypothesis, showing that the season had no effect on LOS or 30-day readmission rates, was accepted. Some healthcare providers did not notice the positive impact of the CBAHI accreditation. This may support the fourth null hypothesis, which states that the CBAHI accreditation does not improve healthcare delivery from the healthcare provider\u0026rsquo;s perspective.\u003c/p\u003e \u003cp\u003eThis study has some limitations. The JCI accreditation was conducted before the CBAHI, which may introduce some bias. This study included only two hospitals in the Eastern province of Saudi Arabia. In addition, the sample size was small; only 149 out of 200 individuals completed the survey.\u003c/p\u003e \u003cp\u003eFuture studies should include different types of hospitals in different regions of the KSA to obtain a more comprehensive picture of the impact of the CBAHI accreditation, increase the period before and after accreditation, and include more than two patient clinical outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBAHI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethe Central Board for Accreditation of Healthcare Institutions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elength of stay, KSA:Kingdom of Saudi Arabia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKPIs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKey Performance Indicators\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANOVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnalysis of Variance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJoint Commission International\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board (IRB) at Imam Abdurrahman bin Faisal University through an expedited review on Wednesday, January 18, 2023 (IRB number: IRB-UGS-2023-03-028). All procedures involving human subjects adhered to the guidelines specified in the Declaration of Helsinki. Patient identities in the data collected in Phase 1 were anonymized, and information was accessible only to the study researchers. In Phase 2, an informed consent was signed by the healthcare providers prior filling out the questionnaire.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe data of this manuscript is avaliable upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funding was received for this study.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eA.W, S.A, and N.A contributed in selecting the proper methodology, data collection, interpretation the findings, and drafting the research manuscript. A.A, and F.A contributed in the conceptualization, data interpretation and finalizing the final version of the manuscript. L.A contributed in making throrough review of the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNA\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlkhenizan A, Shaw C. The attitude of health care professionals towards accreditation: a systematic review of the literature. J Fam Community Med 2012;19(2):74\u0026ndash;80. doi:10.4103/22308229.98282\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsakkak MA, Alwahabi SA, Alsalhi HM, Shugdar MA. Outcome of the first Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) primary health care accreditation cycle in Saudi Arabia. Saudi Med J 2017;38(11):1132\u0026ndash;6. doi:10.15537/smj.2017.11.20760\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlqarni A, Kattan W, Alzahrani K, Elkhashab A. The impact of CBAHI accreditation on efficiency rate and patient safety: Makkah experience, KSA. 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Bmj, 2018;363.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee BY, Chun YJ, Lee YH. Structure, function, and impact of hospital accreditation in South Korea. J Hosp Manag Health Policy 2021;5:31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaccioni A, Sicotte C, Champagne F. Accreditation: a cultural control strategy. Int J Health Care Qual Assur 2008;21(2):146\u0026ndash;58. doi:10.1108/09526860810859043\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaeda AM. Nurses\u0026rsquo; perceptions of quality improvement during accreditation in Saudi Arabia. Asian Nurs Res 2012;6(2):59\u0026ndash;67. doi:10.1016/j.anr.2012.07.001\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaikh ZM, Al-Omari A, Ahmed A. The impact of CBAHI accreditation on critical care unit outcome quality measures: a case study. Int J Health Sci Res 2018;8(7):394\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Vliet EJ, Soethout J, Churruca K, Braithwaite J, Luxford K, Stewart J, et al. International approaches for implementing accreditation programmes in different healthcare facilities: a comparative case study in Australia, Botswana, Denmark, and Jordan. International Journal for Quality in Health Care. 2023; 35(2):1\u0026ndash;12. doi:10.1093/intqhc/mzad026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWardhani V, van Dijk JP, Utarini A. Hospital accreditation status in Indonesia: associations with performance indicators. BMC Health Serv Res 2019;19:372. doi:10.1186/s12913-019-4187-x\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"accreditation, patient outcomes, readmission, length of stay, healthcare quality, Saudi Arabia","lastPublishedDoi":"10.21203/rs.3.rs-8076168/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8076168/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe Central Board for Accreditation of Healthcare Institutions (CBAHI) was introduced in Saudi Arabia to enhance healthcare quality and patient safety. However, empirical evidence on its effectiveness in improving patient outcomes is scarce.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjectives\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo evaluate the impact of the CBAHI accreditation on hospital length of stay (LOS) and 30-day readmission rates, assess seasonal variation in these outcomes, and explore healthcare workers\u0026rsquo; perceptions of accreditation in different hospital settings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA pre-post quantitative analysis was conducted using (Key Performance Indicators) KPIs data from a private hospital from 2019 to 2022, covering periods before, after, and one year post-CBAHI accreditation. Additionally, a cross-sectional survey was administered to 149 healthcare providers at a private and quasi-governmental hospital at the Eastern Province of Saudi Arabia to determine staff perceptions of the impact of the accreditation on improving healthcare delivery. The English version of the questionniare is provided in Appendix 1.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA statistically significant reduction in LOS was observed after accreditation (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), though the 30-day readmission rates increased slightly (p\u0026thinsp;=\u0026thinsp;.027). No significant seasonal variation was found. Survey results revealed mixed perceptions of accreditation, with higher engagement and perceived benefits reported by semi-government hospital staff and those with bachelor\u0026rsquo;s degrees.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe CBAHI accreditation appears to improve LOS but has a limited impact on readmission rates. Healthcare providers\u0026rsquo; perceptions vary according to hospital type and involvement in the accreditation process. These insights may guide future improvements in accreditation practices and implementation strategies.\u003c/p\u003e","manuscriptTitle":"The Impact of the CBAHI Accreditation on Patient Outcomes: Evidence from Two Hospitals in Eastern Saudi Arabia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 09:59:50","doi":"10.21203/rs.3.rs-8076168/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-12T06:33:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-31T09:34:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184932763382629107093838675547332144797","date":"2025-12-28T19:03:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127905059189513898143739674346426391029","date":"2025-12-28T04:03:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-27T20:15:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49768128427492589910000469379865299071","date":"2025-12-25T22:13:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-25T17:19:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-22T16:13:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-02T06:13:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-01T13:18:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-12-01T12:03:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9957edb8-cce8-4d0b-901f-c57c66e5d91c","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-30T09:59:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-30 09:59:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8076168","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8076168","identity":"rs-8076168","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}