PONE-D-24-56923Healthcare professionals' perceptions about implementing accreditation as a strategy to improve healthcare quality and organisational performance: a cross-sectional survey studyPLOS ONE

Dear Dr. Alhawajreh,

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this manuscript, which explores an important and timely topic in healthcare management. Below, I provide detailed feedback (as requested) on the manuscript, addressing its technical soundness, statistical analysis, data availability, and overall clarity.

Introduction:

The introduction provides a strong starting point, effectively highlighting the significance of accreditation in healthcare. However, the study could benefit from being more explicitly positioned within the global context. Including contrasting findings from high-income countries, such as the US, Canada, or Australia, would provide valuable comparisons and enhance the discussion. Furthermore, while the rationale for focusing on public hospitals in Jordan is clear, expanding on how these findings could inform accreditation practices in similar healthcare systems would be beneficial. It’s worth noting that Jordan faces unique challenges, such as resource constraints, workforce shortages, and its role as a regional hub for refugees. Acknowledging these factors would strengthen the relevance of the study to other resource-limited settings.

Background:

The background lays a solid foundation by linking global healthcare challenges to the need for quality improvement strategies like accreditation. However, this section could be further strengthened by addressing the mixed evidence surrounding accreditation’s effectiveness. While the manuscript mentions conflicting findings, incorporating specific examples of studies showing both positive and critical outcomes would add balance. Additionally, the limited research on accreditation in the Eastern Mediterranean Region is highlighted but not fully explored. Expanding on the barriers to research in this region, such as data accessibility and resource limitations, would provide valuable context. A smoother transition connecting global challenges, regional gaps, and the study’s specific objectives would further enhance the narrative.

Methods:

The methods section is clear and comprehensive, with a well-defined study design and robust data collection process. The use of a web-based questionnaire and the strong response rate (74.4% of 500 invited participants) are commendable. However, the manuscript does not provide details on whether the questionnaire was adapted to reflect Jordan’s cultural or healthcare context. Addressing this point would enhance transparency and show that the instrument was appropriately tailored for the study population. Additionally, while the statistical methods are appropriate, a brief explanation of why non-parametric tests like Kruskal-Wallis were chosen over parametric alternatives would be useful. For instance, clarifying whether assumptions of normality or homogeneity of variance were tested and found to be violated would strengthen the methodological justification.

Results:

The results are presented clearly, with effective use of tables and figures to summarise key findings. The strong positive correlation between healthcare professionals’ perception of Quality Results and other accreditation scales is well-supported by statistical analysis. Briefly highlighting how observed differences between clinical and administrative staff might impact accreditation outcomes would add depth to the findings.

Discussion:

The discussion provides a thoughtful interpretation of the findings and successfully links them to broader improvements in healthcare quality and organisational performance. While the discussion acknowledges the study’s strengths, it could benefit from a more critical evaluation of its limitations, particularly the low patient awareness (47%) of accreditation. This finding has important implications for the effectiveness of accreditation programs and deserves further exploration. Additionally, engaging more deeply with contrasting findings from international studies would help contextualise the results within the broader accreditation literature. Although variations in perceptions between professional groups are mentioned, a more detailed analysis of these differences could further enrich the discussion.

Conclusion:

The conclusion effectively summarises the study’s main findings and underscores the positive impact of accreditation. However, I suggest including more actionable recommendations for policymakers and practitioners. For example, strategies to enhance patient awareness and better align perceptions between clinical and administrative staff could be discussed. Moreover, it would be helpful to explicitly acknowledge the study’s limitations, such as its focus on public hospitals, which may limit the generalisability of the findings. Proposing future research directions, such as exploring accreditation in private hospitals or other resource-limited settings, would strengthen this section.

Overall Evaluation:

This manuscript provides valuable insights into accreditation in the Eastern Mediterranean Region, filling an important gap in the literature. While the study is technically sound and well-structured, the suggested revisions would enhance its clarity, contextualisation, and overall impact. I recommend minor revisions to address the outlined concerns and ensure the manuscript reaches its full potential.

Reviewer #2: The study addresses an important topic and includes promising elements, such as studying four hospitals of different sizes, providing an interesting comparative analysis opportunity. However, several areas need significant improvement to enhance your work's clarity, rigor, and impact. Below are my detailed suggestions:

(1) References: Incorporate more recent studies, particularly those published in the last 3–5 years, to ensure the discussion reflects the latest hospital management and accreditation advancements (e.g., Araujo, C. A., Siqueira, M. M., & Malik, A. M. (2020). Hospital accreditation impact on healthcare quality dimensions: a systematic review. International Journal for Quality in Health Care, 32(8), 531-544.)

(2) Forced-Response Bias: The questionnaire design does not include a "Don't know" or "Not applicable" option and requires participants to respond to every question. This approach may introduce response bias, as participants may choose arbitrary answers when they lack knowledge or opinion on a particular question.

(3) Case Selection: Including two large and two small hospitals is a strength, but the manuscript does not explain the rationale behind their selection. Please elaborate on the criteria for choosing these hospitals and how their characteristics align with the study's objectives. Also, as proposed by Yin, this strategy of selecting units with different characteristics is very rich and should be used to compare the results and further understand the results in various contexts. The authors should take advantage of this choice. Another issue is the triangulation of the findings, which is essential in case study research to ensure the validity of conclusions.

(4) Lack of Practical Implications: The findings would benefit from further interpretation regarding practical implications for hospital management or policy. How can these results inform decision-making or operational improvements?

(5) Include three paragraphs in the Conclusion section to clarify the research contributions to academics, managers, and society. Please, one paragraph for each dimension.

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Reviewer #1: No

Reviewer #2: Yes: Claudia Araujo

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Healthcare professionals' perceptions about implementing accreditation as a strategy to improve healthcare quality and organisational performance: a cross-sectional survey study

PONE-D-24-56923R1

Dear Dr. Alhawajreh,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Maher Abdelraheim Titi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed all the review comments thoughtfully and comprehensively. The revisions improve the clarity, contextualisation, and methodological transparency of the manuscript. Key additions, such as the expanded discussion on global accreditation practices, the clarification of methodological choices, and the enhanced recommendations for policymakers, have strengthened the study’s contribution.I have no further comments.

Reviewer #2: Thanks for the reviewed version. The authors have addressed all the comments and made the necessary changes in the manuscript.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Claudia Araujo

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