The interactive effect of applying the management-centered standards of Joint Commission International (JCI) and practicing administrative control in improving the quality of health services: a study on three Yemeni hospitals seeking accreditation

Introduction

The quality of health services is of utmost importance in ensuring the well-being and safety of patients. To achieve this, healthcare organizations strive to implement effective, management-centric standards that align with best practices (1).

The Joint Commission International (JCI) for Hospital Accreditation is a global organization focused on improving the quality of health services and patient safety through a set of established standards. Some of these standards are patient-centered, and others are management-centered (2). Management-focused standards play a vital role in improving the quality of health services (3). These standards provide a comprehensive framework covering various aspects, including quality and patient safety (QPS), prevention and control of infections (PCI), governance, leadership, and direction (GLD), facility management and safety (FMS), staff qualifications and education (SQE), and management of information (MOI) (4). By implementing these standards, healthcare organizations can ensure that their practices align with globally recognized best practices, leading to improved patient care and safety (2).

In addition to adhering to management-focused standards, healthcare organizations also need to implement management control measures (5). Administrative control refers to the oversight of health services operations, including policies, procedures, and protocols (6). By exercising effective administrative control during the implementation stages of health services, including preventive control (PC), executive control (EC), and results control (RC), health institutions can ensure that their operations are streamlined, risks are identified and mitigated, and resources are used optimally (7).

Previous research has shown that both JCI accreditation and effective administrative control can independently lead to improved health services quality in various settings. Studies conducted in the United States revealed that JCI-accredited hospitals reported significantly lower patient mortality (8).

Stronger adherence to certain JCI standards, such as leadership management and infection prevention, is associated with reduced infections in healthcare (9).

Areas emphasized by the JCI, such as QPS programs, have also demonstrated benefits when paired with administrative commitment abroad. A Canadian study linked active senior management involvement in incident reporting with nearly double the odds of capturing adverse events compared to sites with less engaged oversight (10).

Previous research has shown that variables such as ownership, size, and age can impact a hospital’s structure and processes of care (11,12). Studies show that public hospitals tend to have lower quality ratings than private facilities, potentially due to resource constraints (13). Larger hospitals generally report better performance on clinical measures since economies of scale allow more specialized services (14). Older hospitals may face greater challenges maintaining up-to-date infrastructure and technology than newer facilities (15).

Within Yemen, one study revealed that management control measures such as protocol implementation and staff training, as mandated by JCI standards, led to a 31% reduction in central line infections at a single hospital over 2 years (16).

There is a scholarly perspective that management-centric standards alone may be inadequate to substantively and sustainably enhance health services quality over time (17). Proponents of this viewpoint assert that a synergistic relationship between such external regulatory frameworks and internal administrative controls is paramount (18). This provided theoretical justification for the current study’s examination of the interactive effects between the implementation of JCI’s management-oriented accreditation requirements and hospitals’ application of management oversight practices.

This research aimed to explore the interactive impact of applying JCI management-centered standards and exercising administrative control on improving the quality of health services. By examining the relationship between these two factors, we can gain insight into their combined effectiveness in enhancing health care quality and patient outcomes. The “interactive impact” of JCI standard implementation and management control refers to the combined or synergistic effect of adhering to both external accreditation protocols and internal administrative processes working jointly toward improved healthcare quality.

By studying healthcare organizations that have successfully implemented management-focused standards and effective management control measures, we can identify potential synergies and challenges in integrating these practices. This research will provide valuable insights into how healthcare organizations can improve their operations, enhance patient safety, and improve the overall quality of healthcare.

This study contributes to the existing body of knowledge by exploring the interactive impact of implementing the management-focused standards of JCI and exercising management control on improving the quality of health services. By understanding the relationship between these two factors, healthcare organizations can make informed decisions and implement strategies that lead to better patient outcomes and improved healthcare quality.

Theoretical framework

Several theories provide useful lenses for understanding how accreditation standards and management practices alone and in combination may shape health services quality outcomes (19). Donabedian’s structure-process-outcome model proposes a foundational role for sound organizational structures and processes in achieving desired clinical outcomes (20). JCI standards focus directly on strengthening structural conditions through criteria evaluating leadership competence, staff qualifications, safety infrastructure, and policy/procedure robustness (2). Administrative control aims to nurture adherence to these structures and promote the delivery of evidence-based care through standardized processes (21).

Institutional theory also argues that conforming to universally accepted norms cultivates legitimacy and reinforces the fulfillment of organizational missions (22). Rules codified in accreditation standards represent a primary source of norms for health systems worldwide (23). However, passive compliance may be insufficient—a strong administration deepens the institutionalization of standards through engaged monitoring and corrective action (24).

Contingency theory suggests that organizational performance is contingent on aligning contextual factors with responses (25). In this case, JCI accreditation exposes contextual standards that set quality expectations (2), while administrative control fine-tunes implementation actions facility-wide (26).

Proper calibration between accreditation guidelines and management strategies may maximize their collective impacts on outcomes (27). For example, lax internal controls may undermine the value of accreditation itself despite structural investments, whereas directing resources disproportionately toward oversight risks negating benefits from standard setting (28).

An integrated perspective based on structure-process-outcome, institutional, and contingency theories therefore inform the following hypotheses:

• H1: implementing JCI standards will improve the quality of health services;
• H2: practicing administrative control will improve the quality of health services;
• H3: JCI standards and administrative control have interactive effects on improving the quality of health services;
• H4: there are statistically significant differences based on the variables of hospital ownership, year of hospital opening, and hospital size.

Methods

This study was conducted between January 2023 and December 2023. The core research team involved two management professors from Sana’a University in Yemen. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional ethics board of Federation of Private Hospitals (No. 90-2023) and informed consent was obtained from all individual participants.

Model

Cognitive models in research help identify associations between specific cognitive processes and experimental interventions, enhancing understanding of human cognitive functions (29). The cognitive model was developed to examine the interactive impact of applying the management-centered standards of the JCI and practicing administrative control in improving the quality of health services as follows:

• The dependent variable (the quality of health services): the SERVPERF scale for Perry et al. [1982] was used. The most appropriate measure for assessing quality of service (30). The scale consists of five dimensions: tangible aspects, credibility, safety, responsiveness, and sympathy (31). These dimensions have been shown to adequately capture important aspects of healthcare service delivery through extensive testing of patient populations (32). SERVPERF has demonstrated high reliability, validity, and generalizability across cultural settings through applications in various industries, including healthcare (33). Its proven performance as a measurement tool supported its selection for this research.
• The independent variable (JCI): the sixth dimensions of the management-centered standards of the JCI were used: QPS, PCI, GLD, FMS, SQE, and MOI.
• The independent variable (administrative control): the Goeble and Weibenberger scale was used (34). The scale has three dimensions: PC, EC, and RC.

The cognitive model is shown in Figure 1.

Figure 1 The model. PC, preventive control; EC, executive control; RC, results control; MC, management control; GLD, governance, leadership, and direction; MOI, management of information; PCC, patient-centered care; PCI, prevention and control of infections; QPS, quality and patient safety; SQE, staff qualifications and education; JCI, Joint Commission International; JCIA, Joint Commission International accreditation; QS, quality of services.

Questionnaire

The questionnaire was administered once to each respondent. The questionnaire consisted of three components that included the study variables (quality of health services, JCI standards, and administrative control). Additionally, the questionnaire comprised 45 items. The questionnaire items were scored on a 7-point Likert scale as follows:

• Strongly agree [88–100];
• Agree [75–87];
• Somewhat agree [62–74];
• Neutral [49–61];
• Somewhat disagree [36–48];
• Disagree [23–35];
• Strongly disagree [0–22].

To estimate the average score on this scale, the responses to each statement were summed, and the sum was subsequently divided by the number of respondents to obtain the average score. The average closest to 1 represents the highest degree of agreement, while the average closest to 7 represents the lowest degree of agreement. An average closer to 4 represents a neutral view. The questionnaire was characterized by high validity, with a Cronbach’s alpha value of 0.797 to adequately capture respondents’ understanding and perceptions of these conceptual areas, as shown in Table 1.

Sample

The study sample consisted of three hospitals that had been actively working to strengthen QPS management systems through voluntary adoption of JCI standards and guidelines for 2–3 years at the time of this study as part of an overarching hospital quality improvement initiative. Formal accreditation certification had not yet been obtained. Staff had received training on JCI requirements, and the hospitals were in various phases of implementing structural and procedural changes recommended by the JCI.

The three hospitals included in this study had one private partnership, the other public partnership, and the third public-private partnership (PPP). All hospitals were established between 2005 and 2008.

All three facilities provide comprehensive inpatient and outpatient care across major clinical specialties. They serve as regional referral centers and engage in clinical training programs. To select the random sample of clinical staff for this study, the following process was undertaken:

• An up-to-date staff roster for each hospital was obtained from human resources, listing all personnel by department/unit;
• A sampling frame was constructed, including all eligible staff, which were full-time employees;
• An online random number generator was used to assign sequential numbers to each name on the sampling frame;
• The required sample size for each hospital was calculated based on its total eligible staff size to obtain approximately 10–15% representation per facility;
• The selected staff members were notified and invited to participate;
• Replacements for any non-responders were chosen from the sampling frame by selecting the next randomly numbered names until full participation was obtained;
• This process helped ensure that an unbiased representative sample was drawn from each hospital population in a standardized randomized manner while achieving adequate response rates.

The population members represented all the medical staff in the hospitals under study (physicians, nursing staff, and supportive medical services), which numbered 1,606. The sample members were selected according to the sampling table of Krejcie and Morgan [1970] (35). Therefore, the sample size was 310. There were 243 valid responses for analysis. The sample members were selected in a simple random manner.

Statistical analysis

The data were analyzed using SPSS, version 27 (IBM Corp., Armonk, NY, USA). The means, standard deviations (SDs), frequencies, and percentages (%) are presented. Statistical significance was set at P<0.05. Structural equation modeling (SEM) was performed via partial least squares (PLSs) using the statistical analysis program Smart PLS [2018-9] to test the hypothesized relationships between variables due to its ability to simultaneously assess multiple independent and dependent constructs (36). SEM allows for the confirmatory assessment of theoretical models through the estimation of both direct and indirect effects (37). It has gained popularity in organizational and health services research for modeling complex associations (38).

The study model is a multivariate and multidimensional model. The SEM method is one of the best methods used to test multivariate models and their suitability (39). Smart PLS is also used to develop measurement models, including reflective and formative measurement models.

The normality of the residuals was examined through visual inspection of histograms. The data are distributed in a bell shape around the average error, which is equal to 0. This normal distribution of the residuals means that there is an approximately equal probability of positive and negative values and that most errors are small (see Figure 2).

Figure 2 Normality of residuals.

The normality of the data was checked using the Kolmogorov-Smirnov test, and parametric tests were used for analysis since the data followed a normal distribution (P>0.05).

Results

The level of application of the variables and dimensions of the study

Regarding the level of application of accreditation standards (JCI), Table 2 shows a mean of 6.13 (SD =0.45), representing a high level of 87.6% according to community members. All JCI dimensions scored highly to very highly. PCI ranked highest (mean =6.27; SD =0.64; 89.6%), while FMS ranked lowest (mean =5.96; SD =0.91; 85.1%).

Administrative control practices were also high (mean =5.98; SD =0.60; 85.4%). All dimensions scored highly to very highly. PC ranked highest (mean =6.22; SD =0.55; 88.8%), whereas RC ranked lowest (mean =5.75; SD =0.86; 82.2%).

Table 2 further shows that health service quality was very high (mean =6.17; SD =0.52; 88.2%), with all dimensions scoring very highly. “Safety” ranked highest (mean =6.24; SD =0.60; 89.2%), while “reliability” ranked lowest (mean =6.10; SD =0.72; 87.1%).

Hypothesis testing

Table 3 indicates that the application of JCI accreditation standards has a statistically significant positive effect on health service quality improvement. The multiple linear regression model showed a standardized beta coefficient of 0.639 for the JCI standards (t=15.155; P<0.001). Thus, the first hypothesis that JCI accreditation standards improve health service quality is accepted, with the results being statistically significant at the P<0.05 level.

Additionally, Table 3 indicates that administrative control practices have a statistically significant positive effect on health service quality improvement. The multiple linear regression model revealed a standardized beta coefficient of 0.565 for administrative control practices (t=11.259; P<0.001). Thus, the second hypothesis that administrative control practices enhance health service quality is accepted, with the results being statistically significant at the P<0.05 level.

Moreover, Table 3 examines the interaction effect of applying JCI standards and practicing administrative control on health service quality improvement. Multiple linear regression analysis yielded a standardized beta coefficient of 0.075 for the interaction term (t=1.801; P=0.04). Therefore, the third hypothesis that a combined interactive effect of JCI standards and administrative control practices significantly improves health service quality is accepted, as the results were statistically significant at P<0.05. The effect size of 0.014 confirmed the substantiated interaction impact, exceeding the minimum threshold value of 0.002.

Table 4 shows whether hospital ownership, age, and size moderated the relationship between JCI standards/administrative controls and the quality of health services. The results showed no statistically significant differences for any of the moderating variables, as the significance levels were all greater than 0.05. Therefore, the fourth hypothesis that hospital characteristics moderate the aforementioned relationships is rejected, as the moderation effects were not statistically significant.

Discussion

The present study aimed to investigate the interactive impact of applying the JCI standards and administrative control practices on healthcare quality.

The questionnaire was high validity, a Cronbach’s alpha value of 0.797. This means that the scale is reliable for assessing the quality of health services in the context of the present study.

Healthcare quality was measured using the SERVPERF scale. The results revealed high overall application (mean =6.17; 88.2%), with all dimensions scoring highly. The first independent variable was the JCI standard, which included various dimensions. The results revealed high overall application (mean =6.13; 87.6%), with all dimensions scoring highly. “PCI” ranked highest, and “FMS” ranked lowest. The second variable was administrative control, assessed by the PC, EC, and RC dimensions of the Goeble and Weibenberger scale. Administrative control practices were also high (mean =5.98; 85.4%), with all dimensions scoring highly and “PC” ranking highest.

Regression analyses revealed that JCI standards positively impacted quality (β=0.639; t=15.155) and that administrative control significantly enhanced quality (β=0.565; t=11.259). An interaction effect was detected (β=0.075; t=1.801), indicating that combined implementation strengthened quality outcomes. Moderation by hospital characteristics was not significant. The findings provide valuable insights into the relationships among these factors and highlight the importance of their integration for enhancing healthcare quality.

Previous research has examined the impact of the JCI on various aspects of the structure-process-outcome framework. In terms of structure, accreditation has been shown to strengthen organizational resources such as staffing, facilities, and quality infrastructure (40). Compliance with physical and administrative standards indicates enhanced structural capacity (41).

Regarding processes of care, studies have shown that JCIs are associated with improved infection control practices [9], evidence-based clinical guidelines (42), and patient safety culture scores [3]. Adherence to standards rationalizes care delivery systems (43).

Outcome studies have reported lower complication rates, decreased mortality, and greater patient satisfaction post-accreditation (44). Metrics reflecting distal outcomes demonstrate quality consequences (45).

The survey-based results of the present study suggest that JCI cooperation with management control positively influences the dynamic interactive “process” element by harmonizing external accountability with the internal alignment of quality systems. This operational interface between accreditation and administration represents an acknowledged yet under investigated aspect of the structure-process-outcome conceptual framework. Future research broadening measurement across the multidimensional model could offer fuller insight into mediators and modifiers throughout the accreditation experience.

The findings provide insight primarily applicable to other hospital organizations in resource-limited settings that are in early stages of the accreditation preparation process through self-assessment and continuous compliance efforts prior to formal surveys. The generalizability may be limited to facilities proactively working to interpret and enact JCI protocols to enhance quality versus those passively applying standards only as part of mandatory accreditation.

This additional context clarifies the accreditation engagement stage and status of the three participating hospitals, improving the understanding and applicability of the results.

These results align with prior studies showing that accreditation standards coupled with strategic management controls can optimize quality outcomes. Like investigations in other countries, implementing JCI requirements while actively overseeing core processes through protocols and staff development was beneficial (42,46).

Similarly, hospitals in Yemen and resource-constrained contexts may consider emphasizing team-based approaches, clear accountability, and data-driven solutions advocated by standards to strengthen limited systems. Leadership rounding, frontline problem-solving teams, and digital tracking of metrics are low-cost methods for increasing adherence, and sustainability has been shown to be effective elsewhere (47). Continuous professional education programs for management could also bolster administrative capacity on par with high-income countries, demonstrating mastery of integration between external oversight and internalized ownership of quality culture that persists over time (48).

Assessing other dimensions of patient results would provide a well-rounded perspective for facilitating wider application. However, these preliminary governance insights offer modifiable leverage points for enhancing services across Yemen’s healthcare infrastructure through complementary self-regulation and situated problem solving.

Overall, the findings of this study provide evidence that the integration of the management-centered standards of JCIs and administrative control practices has a positive and interactive impact on improving the quality of health services. These findings align with previous research that emphasizes the importance of standard-based accreditation and effective management practices in healthcare organizations (2,3,7,49). Furthermore, the results highlight the significance of a multidimensional approach to quality improvement and underscore the need for continuous evaluation and enhancement of healthcare practices.

However, it is important to acknowledge some limitations of the present study. First, the sample size was relatively small, consisting of only three hospitals. Therefore, caution should be exercised when generalizing the findings to a broader population. Additionally, the study relied on self-reported data, which may be subject to social desirability bias. Future research should aim to replicate these findings using larger and more diverse samples, as well as employing objective measures of healthcare quality. A limitation of the study is that the final sample size of 243 valid responses was lower than the 310 estimated in the sample size calculation. This could impact the statistical power and generalizability of results. However, we aimed to select a representative sample from the total population of 1,606 medical staff using a validated sampling method and high response rate. Future studies with larger sample sizes are still needed to confirm these findings.

In conclusion, this study provides valuable insights into the interactive impact of applying the management-centered standards of JCIs and practicing administrative control on improving the quality of health services. The results indicate that both JCI standards and administrative control practices play a crucial role in enhancing healthcare quality. The findings contribute to the literature and have implications for healthcare organizations and policymakers aiming to improve the quality of health services.

Conclusions

The findings provide evidence that adherence to JCI standards and administrative control practices are positively and interactively associated with health services quality. The implementation of JCI standards was found to significantly predict quality, as was the practice of administrative control. An interaction effect also indicated that their combined application strengthened quality outcomes. These results align with prior research emphasizing the importance of standard-based accreditation and effective management for improving organizational performance in health services.

Notably, this study contributes to the understanding gained from examining the interactive, as opposed to isolated, impacts of JCI standards and administrative control on quality. A multidimensional approach to quality management is supported. The findings offer insights for healthcare administrators seeking to integrate accreditation standards and management practices for enhanced service delivery.

The study also presents an innovative approach, which involves adding a section on administrative control to the JCI standards, as it provides strength and continuity to the implementation of the standards, which is reflected in the quality of health services.

Acknowledgments

Funding: None.

Footnote

Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-47/dss

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-47/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-47/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional ethics board of Federation of Private Hospitals (No. 90-2023) and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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