Introduction

Accreditations have been part of healthcare for a long time [1]. Accreditation systems have become integral parts [2–4] partly due to globalisation and the growth of medical tourism [5]. International accreditations have emerged alongside national systems to enable the assessment of hospital quality across borders, focusing on standardising protocols to maintain efficiency and safety [6].

Systematic monitoring of work atmosphere and patient safety incidents is an essential component of any quality assurance system. Accredited systems, such as the Joint Commission International (JCI), are particularly emphasised. Because accreditation entails a large investment, evaluating its benefits is important. Some studies have investigated these benefits [7–9] but evaluating these accurately is difficult and studies are heterogenous. The quality assurance systems are widely used in healthcare and other sectors [10,11], but how their implementation affects staff well-being and patient safety remains underexplored [12–15]. It is reasonable to assume that well-being at work and work satisfaction are strongly correlated with good outcomes in healthcare service delivery, including patient safety [16–18]. Thus, examining both motivating and demotivating factors for staff is essential when studying the effects of quality assurance systems [12,19]. In line with the study’s focus, this research emphasises staff experiences and the practical implementation of accreditation, rather than technical or regulatory details, to maintain clarity and relevance to the research questions.

In this study, we examine a particularly distinctive case: a Finnish private hospital specialising in orthopaedic surgery (joint replacements and back surgery) and rehabilitation. The hospital experienced an ownership transfer to a public hospital organisation during the COVID-19 pandemic, providing a unique context in which accreditation coincided with significant organisational change. These circumstances allow us to explore how accreditation interacts with staff well-being, patient safety, and organisational resilience under rarely studied conditions, highlighting the interplay between organisational change, crisis management, and quality initiatives.

Determining the effects of quality assurance systems is challenging due to multiple confounding factors, such as hospital size, patient health status, and management culture [20]. Accreditation and hospital quality system implementation are expensive and time-consuming, which can create legitimacy concerns for hospital management [21,22]. Previous research has examined accreditation outcomes in various contexts [23–25]. However, little attention has been paid to staff attitudes during concurrent crises or in Nordic private hospital settings.

Work satisfaction comprises favourable or unfavourable feelings and emotions employees associate with their work [26]. Work satisfaction can be considered more subjective than well-being and is considered more subjective than well-being [27]. Well-being at work is a more comprehensive concept that includes job satisfaction, though the distinction is minimal [28,29].

Patient safety and employee well-being are correlated [30–34]. We investigate the effectiveness of hospital accreditation system regarding patient safety and employee well-being using a qualitative approach, to provide a comprehensive picture of the hospital during the introduction of the quality system. As Øvretveit and Gustafson [35] noted that accreditation costs can be minimised if implementation is efficient. Factors critical for success include management and physician engagement at all levels, robust data systems, appropriate training, and effective project team management [36]. By focusing on staff perceptions and experiences, this study directly addresses the research questions and ensures that background information supports understanding the rationale for examining these perceptions

This qualitative study explores hospital staff perceptions of the implementation of a quality assurance system, aiming to describe their experiences and views on the system established in a Finnish private hospital. It contributes to international literature by examining accreditation in a Nordic private hospital, which is underrepresented in previous research. The focus on an orthopaedic specialist hospital adds relevance, as surgical care and rehabilitation require standardised processes and present specific patient safety challenges. Moreover, the simultaneous ownership transition and the COVID-19 pandemic create a rare opportunity to explore accreditation under conditions of organisational change and crisis. Together, these factors allow the study to shed light on how accreditation influences staff attitudes, well-being, and perceptions of patient safety in a highly dynamic environment—a perspective largely absent from prior studies.

The research questions are as follows:

1. What are the expectations of the staff regarding the implementation of the quality assurance system?
2. What advantages and disadvantages do hospital staff perceive in the implementation of the quality assurance system?

Materials and methods

This qualitative research was conducted through seven focus group interviews to determine the perceptions of different hospital staff towards the quality system and its implementation. The purpose of the qualitative interviews was to broaden personnel’s baseline views, conceptions and expectations regarding quality assurance and their own well-being before the implementation of JCI standards.

The study was conducted in a Finnish private hospital specialising in orthopaedic surgery (joint replacements and back surgery) and rehabilitation. Data was collected during two periods: in 2020 and in 2022. These periods coincided with an ownership transfer and the COVID-19 pandemic, creating a context of organisational change and crisis management.

The interviewed focus groups comprised randomly assigned hospital staff. Private practitioners were also included in the study population, so the groups were multiprofessional. For the purposes of the interview groups, all employees of private hospital Orton were compiled into four lists: List 1 comprised physicians, List 2 nurses, List 3 therapists, and List 4 administration, support services, and secretarial staff. In addition, independent practitioners were identified and classified according to the same scheme. Within each list, individuals were arranged in alphabetical order and subsequently assigned a random number generated using Excel’s built-in =RAND() function. The individuals were then reordered based on the random number, which determined their position in the selection order.

Because the aim was to assemble three discussion groups, the first three individuals from each randomised list were invited to participate. In cases of absence or refusal, replacements were drawn in order from the randomised list (starting from the fourth position onward). Participation was voluntary, and each selected individual was given the opportunity to opt out. In total, 156 employees were included in the randomisation process out of a total staff of 196, corresponding to 80% of the personnel at the time. Hourly workers and individuals working less than one day per week were excluded, as were members of the research team. Independent practitioners were included.

Qualitative data were first collected in three thematic group interviews in 2020, and a total of 12 people participated. In 2022, four additional focus group interviews were conducted in which 15 people participated. Thus, a total of 27 employees were interviewed across seven focus groups.

In 2020, three of the twelve physicians (25%) participated, along with three nurses (7.7%), three therapists (13%), and three administrative or other staff members (4%). The 2020 groups included both full-time (9/12) and part-time (3/12) staff. In 2022, four physicians (30%) participated, with the nursing group representation remaining unchanged at 5.8%. Participation increased slightly among therapists (17%) and among administrative or other staff (6%). This composition is broadly reflective of the overall personnel distribution of the hospital at the time.

Across both years, participants represented a wide range of ages (approximately 30–70 years), professional seniority, and employment types (full-time, part-time, and independent practitioners). In 2020, eight women and four men participated, whereas in 2022 nine women and six men took part, resulting in a slightly more gender-balanced sample. Approximately half of the participants in 2022 (50%) had also taken part in the 2020 focus groups, allowing longitudinal comparison of changes in staff perceptions during the implementation of the quality system. The remaining participants were new, as the groups were complemented due to staff turnover between the two data collection points.

These interviews were conducted face-to-face, but one participant took part in one online interview. Each focus group comprised three to four participants representing different professional groups, ensuring that discussions were multidisciplinary and reflected a range of perspectives. At the beginning of each interview, participants were informed about the ethical principles of the study: participation was voluntary, they could withdraw at any time, discussions were confidential, the data would be anonymized, and they had the right to refuse permission for audio recording. The interviews lasted, on average, 51 minutes each, ranging from 34 to 60 minutes. They were conducted in Finnish at two different periods (2020 and 2022) because the research team wanted to understand the changes that had occurred in the participants’ views on the quality assurance system. The interviews were performed by an external interviewer with knowledge of different quality assurance systems and qualitative research. All participants provided written informed consent for both participation in the study and audio recording of the interviews. The researcher also signed a confidentiality agreement to ensure the protection of participant privacy.

Only one of the participants attended the initial training on the JCI quality assurance system. The interviews were recorded with the permission of the participants and transcribed into a total of 162 pages of text.

Results

Discussion

According to the interviewees, the results of this study showed that the introduction of an accredited hospital quality system could help improve the hospital’s common guidelines and processes, including those on the induction of new employees. The implementation of the accredited quality system could also be linked to the hospital’s work atmosphere and well-being at work and work motivation.

Hospital staff linked the accreditation process to hospital management, the operational culture, common goals and the use of the data collected. According to the interviewees, the accreditation system could help highlight the good care services provided by the hospital and reinforced its good reputation. The pursuit of accreditation was linked to the hospital’s identity, image and marketing to attract new customers [38].

The results suggest that accreditation serves both instrumental and symbolic purposes. Instrumentally, the system provided a structured framework to compile guidelines, improve processes, support patient safety, and facilitate staff orientation. Symbolically, accreditation enhanced the hospital’s reputation and marketing appeal, contributing to its identity and external image. This dual role raises critical questions: when does accreditation risk becoming more of a symbol than a practical tool? Several interviewees indicated that the burden of accreditation sometimes overshadowed its practical benefits, suggesting a potential symbolic emphasis:

‘Now that I’m talking, I realise that I’m approaching it in a way that it’s brought in from the outside, without it having any relevance to my work at the moment’. (Interview 2, 2020)

This aligns with literature indicating that externally imposed quality certifications may emphasise image management and marketing over meaningful clinical improvement [39,40].

The symbolic focus of accreditation can have unintended consequences for staff morale and well-being. Interviewees reported feelings of stress, increased workload, and a perception that their clinical work was not directly supported by accreditation activities. This highlights the importance of balancing symbolic recognition with practical utility to maintain engagement and motivation.

‘If we did everything exactly the way, it’s written down (...) there’s no way to follow it to the letter. So yeah, it kind of feels like it could get a bit too rigid, and hopefully, it won’t end up being too strict.’ (Interview 3, 2020)

These findings support previous studies suggesting that accreditation can be perceived as an external imposition if it does not align with staff workflows or local contexts [36].

The enthusiasm for achieving the accreditation ended during the COVID-19 pandemic, the change of ownership of the hospital and other organisational changes a few years earlier. At the same time, Finland began to face a severe shortage of skilled nursing staff and financial challenges for the hospital, the healthcare system and the state economy. Hospital staff was at that point too busy to set up an accreditation system and perceived it as a burden for them.

The key elements in establishing an accreditation of quality assurance systems include clear goals, committed management, systematic processes, the collection of information to support operational improvements, an organisational culture that fosters accreditation and quality assurance and a willingness to enhance practices [41]. Implementation must consider contextual readiness, including financial and organisational stability, and staff availability to engage meaningfully in quality assurance processes [38].

Quality assurance systems are needed in healthcare. Quality assurance is a continuous, internal process aimed at ensuring that services and processes meet specified standards. Accreditation focuses on maintaining and improving standards of care as well, but it is a formal, external validation process by an independent accrediting body requiring a rigorous review, including documentation, site visits and periodic reassessments. This study critically emphasizes that if accreditation is pursued mainly for external recognition or marketing, its instrumental value for improving safety, efficiency, or staff well-being may be limited.

However, the added value of accreditation is difficult to examine using a comparative study design for practical and ethical reasons [42]. When pursuing major initiatives, such as accreditation, hospitals need to evaluate the corresponding outcomes. With an efficient quality assurance system, employees experience increased feelings of coherence, leading to improved well-being at work [43]. Externally accredited quality has an impact on a hospital’s brand and marketing, which in turn may cause extra burden for the employees. These insights suggest that the implementation of accreditation should balance symbolic and instrumental objectives. Hospitals should consider carefully whether accreditation initiatives are genuinely aimed at improving patient safety, operational efficiency, and well-being at work, or if they are primarily pursued for external recognition. Future research could explore the long-term consequences of symbolic versus instrumental accreditation, and how different implementation strategies affect staff engagement, well-being, and organisational resilience. The qualitative findings of this study provide a basis for hypothesis generation and suggest that more nuanced, context-sensitive approaches to accreditation are needed in healthcare systems with stringent regulatory environments. This study contributes to a better understanding of how accreditation should be adapted to the specific circumstances of different hospitals in various countries, where regulation and legislation may vary significantly.

There are many potential confounding factors in this field of research, as healthcare is culture specific and strictly regulated by law. The strength of qualitative research is that it brings out perspectives that have not been integrated into the research questions. The qualitative approach to research is exploratory and helps develop hypotheses for future research [37].

Strength & limitations

The study offers valuable insights into the establishment of a quality system during the COVID-19 pandemic. The findings highlight the challenges faced by a private hospital as it encounters multiple changes simultaneously. Since the study uses qualitative interview data, it provides in-depth, context-specific insights into the experiences, perceptions, and challenges of healthcare professionals and administrators during the implementation of the quality system at two phases (2020 and 2022). This approach uncovers nuances that quantitative data might overlook, offering a deeper understanding of the interdependencies and complexities involved.

As the study focuses on a private hospital during the COVID-19 pandemic, its findings cannot be directly generalized to public healthcare systems or other environments where resources, patient populations, and operational frameworks differ significantly. Although the qualitative approach provides rich and nuanced insights, it is susceptible to potential bias in data collection and interpretation. The personal perspectives of healthcare staff and hospital administration may not fully represent the broader hospital community, which limits the scope of the findings.

The study was conducted during the COVID-19 pandemic, a period characterised by exceptional circumstances, which may not reflect normal operations. The challenges faced and the solutions implemented may therefore be unique to the pandemic context, thus limiting the applicability of the findings to standard hospital operations.

The study’s sample size is limited, particularly since it focuses on a single hospital and a small group of individuals. This limitation may affect the diversity of perspectives and weaken the generalizability of the findings to other organisations. The study does not account for the long-term effects of the implemented quality assurance system, as the rapid implementation during the pandemic does not allow for a thorough evaluation of the system’s long-term impact on hospital operations. Long-term follow-up would be necessary to assess both the benefits and potential drawbacks of the quality system.

Conclusion

In conclusion, establishing an accredited quality assurance system requires substantial effort and investment raising the question of whether the benefits outweigh the costs. Accreditation initiatives should be adapted to the specific context of the hospital. This includes considering the existing regulatory framework, available resources, and organisational structure, ensuring that the system complements rather than duplicates existing practices. Existing studies indicate that accreditation may be particularly valuable in countries with less robust regulatory frameworks, in settings with sufficient funding and resources, and in areas where national guidelines are lacking or inadequate. In Finland, national-level supervision is already well established and thorough, reducing the marginal benefit of accreditation.

Accreditation occupies a complex position between an instrumental mechanism for improving care and a symbolic marker of legitimacy. While it can standardise processes, enhance safety culture, and promote accountability, its impact often depends on how deeply it is integrated into everyday clinical practice. When accreditation becomes primarily a means of demonstrating compliance rather than facilitating genuine improvement, it risks serving as a symbolic ritual rather than a functional tool. This dynamic reflects a broader tension within health systems, where external accountability mechanisms may incentivise form over substance. The resulting administrative burden can, in turn, erode professional autonomy and contribute to staff fatigue, especially when improvement efforts are perceived as top-down mandates disconnected from clinical realities. Sustaining morale therefore requires leadership that frames accreditation as developmental, not punitive, and ensures that evaluation processes produce tangible learning rather than bureaucratic repetition.

At a systems level, the symbolic weight of accreditation also intersects with growing cross-border mobility in healthcare. Within the European Union, regulatory frameworks enable patients to seek elective care in other member states, introducing both opportunities and vulnerabilities. Accreditation may offer a reassuring signal of safety and quality across jurisdictions, yet this signal can obscure substantial differences in clinical outcomes, follow-up arrangements, and liability standards. In a market where patients increasingly shop for care, the over-reliance on accreditation as a proxy for quality risks commodifying healthcare and amplifying inequities between those able to navigate such systems and those who cannot. A more balanced approach would couple accreditation with transparent, outcome-based data and continuity-of-care safeguards, ensuring that legitimacy derives from demonstrable standards of practice rather than the mere possession of a certificate.

Strong managerial commitment is essential for successful implementation. The study showed that even when staff were generally positive about the quality system, achieving accreditation would have required more dedicated leadership, clear goals, and consistent support from management. Managers play a central role in allocating resources, facilitating processes, and fostering a culture that values quality improvement.

Supporting well-being at work and work satisfaction is critical. Ensuring that employees feel valued, engaged, and equipped with the necessary training and resources contributes directly to the effectiveness of any quality assurance system. A positive work environment, collaborative culture, and open communication between leadership and staff not only sustain morale but also enhance the overall performance and sustainability of quality initiatives.

These findings suggest that the successful implementation of accreditation depends on balancing contextual fit, managerial commitment, and employee engagement. Future research should examine how these factors interact to influence the long-term outcomes of accreditation in healthcare settings with varying regulatory, financial, and organisational conditions

In Finland, national-level supervision is well established and thorough. In countries where such oversight is absent, accreditation plays a crucial role in standardizing hospital operations. While staff generally had a positive attitude towards quality systems accreditation in the present study, even stronger managerial commitment and significant resources would have been needed to achieve the accreditation. Ensuring quality despite limited resources remains a key challenge, requiring effective strategies and innovative approaches.

Supporting well-being at work and work satisfaction is essential for the success of any quality assurance system whether accredited or not. A positive work environment, where staff feel valued and engaged, can contribute to higher levels of motivation and improved performance. Fostering a culture of collaboration, recognition, and open communication between leadership and staff is key to sustaining staff morale and ensuring the long-term success in implementing quality initiatives. Ensuring that staff have the necessary support, training, and resources to carry out quality initiatives is crucial for both their professional satisfaction and the overall success of the hospital.

Supporting information