Dear Dr. Vuohijoki,

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Kind regards,

Elif Ulutaş Deniz

Academic Editor

PLOS ONE

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This work was supported by the Orton Research Institute through grants from the Ministry of Social

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: N/A

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Implementation and Staff Perceptions of a Quality Assurance System in a Finnish Private

1. Abstract:

• The phrase "impact on staff well-being and patient safety" is used, however the abstract doesn't go into detail on staff well-being later on. This produces a gap between the purpose and the findings. So, please make the research goal and the results more similar. You can add results about well-being to the findings.

2. Introduction: The introduction is thorough and well-organised. It talks about the development of accreditation, the gaps in previous research, and the specific goal of the study. Nevertheless, certain amendments are required such as:

• Line 57: "Accreditations have been a part of traditional industries..." Could be reworded to immediately focus on healthcare instead of broad industries.

• Consider compose a concise critical synthesis paragraph clarifying that previous research has examined accreditation outcomes in various situations; however, none have focused on staff attitudes during an associated crisis involving COVID-19 and ownership transfer within a Nordic private hospital environment. This research addresses such gap.

• line 82: "This situation brings up an important question: Is accreditation worth pursuing…?” This is a strong rhetorical question; however, it would be better if it were tied directly to the research goal instead of being left being hanged.

• Line 88, The text calls the difference between work satisfaction and well-being "negligible," nevertheless it is important. This could make it harder for readers to understand. Suggestion: This study asserts that well-being and satisfaction are interrelated dimensions of staff experience.

• The novelty is not distinctly indicated; the introduction resembles a conventional discourse on accreditation rather than providing a compelling rationale for this specific investigation. Through the incorporation of the key characteristics (Finnish private hospital, orthopaedic specialist, ownership transition during COVID-19) are just emphasised at the conclusion and appear to lack significance.

3. Materials and Methods: this section is clear and thorough; however, certain modifications are needed such as:

• Make it clear whether these practitioners work full-time, part-time, or on a temporary basis, as this has a big effect on how people see them.

• Readers can't tell how representative the sample is because there are no percentage distributions for staff groups including doctors, nurses, physiotherapists, and administrative staff.

• The two rounds of data collection conducted in 2020 and 2022 are referenced but lack clear explanation. Were the same individuals involved in the follow-up, or were different groups utilised?

• Include additional information regarding the coding process, triangulation, and the measures implemented to ensure rigour, such as audit trails, reflexivity, and peer debriefing.

4. Result: an extensive dataset, authentic staff perspectives, and a distinctive long-term outlook. However, some amendments are needed such as:

• The current section resembles an introduction rather than an analytical discourse. There are themes, for example: initial optimism, practical benefits, staff well-being, rigidity and workload, contextual constraints, ownership shift, and pandemic disruption; however, they lack clear differentiation It is advisable to split the content into four to six main concepts, accompanied by subheadings. For example:

Initial excitement and optimism (2020)

Perceived benefits include guidelines, orientation, patient safety, and marketing.

Perceived issues include excessive effort, overly strict regulations, and lack of connection to the local context.

Impact of external variables, such as COVID-19, ownership transitions, and staff turnover

Evolution of perspectives over time (reflecting on 2022, progressing towards ISO)

5. Discussion: Balanced and contextual, acknowledging both advantages and disadvantages; however, modifications are necessary such as:

• Strengthen the critique by comparing the instrumental and symbolic aims of accreditation, substantiated by citations. as the section says that accreditation may be more useful for marketing than for patient safety, however this might be critically expanded:

Does certification run the risk of becoming more of a symbol than a tool?

How does this stress effect the morale of the staff?

6. Conclusion:

• The comparison between Arab countries and Finland is presented suddenly, without a grounding in the study's data or supporting sources. It could look like guesswork instead than facts that have been proven. It is prudent to undertake this comparison with enhanced clarity for example, "Existing studies demonstrate that in nations with less robust regulatory frameworks..."

• The conclusion talks about a number of things, such as resources, health, culture, teamwork, and training. Even though all the parts are important, the message seems a little unclear. Think about focussing on two or three main suggestions: making accreditation fit the situation, making sure managers are committed, and using employee satisfaction as a measure of performance.

Reviewer #2: This is an excellent piece of work addressing an important and relatively unexplored area of study. The topic is timely and relevant, particularly given its focus on the implementation and staff perceptions of a quality assurance system in a Finnish private hospital during the COVID-19 pandemic. Below are my detailed comments and suggestions for improvement.

Background

=As the opening chapter, the background requires important revisions. It should serve as the gateway to the problem under study and must remain focused on the research title. Some paragraphs appear tangential and not directly relevant to the topic; I recommend revising these to maintain focus.

= Notably, COVID-19 is not mentioned at all in the background, which is surprising given its centrality to the research. The pandemic context should be explicitly integrated to strengthen the rationale for the study.

= A synthesis of existing literature should be included to demonstrate familiarity with prior work and to clearly establish the research gap.

= The final paragraph of the background (“The research setting is a Finnish private hospital, however owned by a large public hospital...”) would be more appropriately placed under the Methodology section, particularly in the subsection describing the study setting.

Materials and Methods

= The discussion of data collection techniques and analysis approaches is clear and well-articulated.

= However, the methods section would be stronger if it began with the study design and study setting, to provide the reader with a clear orientation before delving into methodological details.

= The description of focus group discussions (FGDs) needs clarification:

o How many FGDs were conducted, and what was the exact procedure?

o Who participated? Were all 12 people plus the additional 16 part of the same groups, or different ones? Please clarify

how the total of 28 participants was organized.

= Provide more detail on participant selection, including criteria, demographic characteristics, and any ethical considerations applied.

= Include a step-by-step description of the data collection process (e.g., how interviews were conducted, whether observations were used, duration, recording, transcription, etc.).

= Expand on the data analysis process: how was the qualitative data processed, coded, and interpreted? Specify the analytical framework or technique applied (e.g., thematic analysis, grounded theory).

= Outline the strategies used to ensure quality and credibility (e.g., triangulation, member checking, reflexivity).

= Provide a clear account of the ethical procedures followed, including consent processes and institutional approval, if applicable.

Results, Discussion, and Conclusion

= These sections are generally well-written and coherent.

= However, I suggest that the strengths and limitations of the study be presented immediately after the discussion. This is a common academic practice and allows the reader to critically assess the scope and validity of the findings.

Overall Impression

The manuscript is strong and promising, but it requires revisions to improve clarity, focus, and methodological rigor. Addressing the above points will enhance the credibility, scholarly value, and overall impact of the study.

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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Implementation and Staff Perceptions of a Quality Assurance System in a Finnish Private Hospital During the COVID-19 Pandemic: A Qualitative Study

PONE-D-25-27467R1

Dear Dr. Vuohijoki,

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,

Elif Ulutaş Deniz

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: Each and every one of the comments has been handled, and the authors have made some outstanding changes.

Reviewer #2: = All the reviewers’ comments and suggestions have been thoroughly addressed, and the manuscript has shown significant improvement. I believe it now meets the required publication standards. Therefore, I recommend acceptance of the manuscript.

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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: No

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