A case study exploring the impact of JCI standards implementation on staff productivity and motivation at the laboratory and blood bank

Abstract Background and Aims Quality of care has transformed to become an essential element of healthcare service delivery, which caused decision makers in Health Care Organisations (HCOs) to seek methods to evaluate the level of care provided. The field of accreditation is under massive development, especially in healthcare organizations. Joint Commission International (JCI) accreditation is one of the accreditation bodies that require a lot of documentation and quality improvement to guarantee proper standard application. The process of accreditation is known to be demanding and requires staff involvement to guarantee successful implementation. Methods This study focuses on the impact of JCI standards implementation on staff productivity and motivation in a 350‐bed hospital. An interpretive approach was used to collect empirical data by interpreting the population's behavior, which is represented in this study by the questionnaire. The study is considered an emergent study that identified, explained, illustrated, and developed a model of staff motivation. In this type of study, the process of inquiry, supporting arguments, and questions of interest is developed after the launching of the study and during the process of data collection. Thus, the researcher relied on the social constructive paradigm, whereby the grounded theory (GT) is used to build the research model of staff motivation during the process of accreditation. Results By studying the Turn Around Time (TAT) performance indicator, the study showed that TAT of tests decreased by 3% after JCI standards implementation, which was reflected at two different laboratory sections. The trainings conducted throughout the process of standards implementation also resulted in enhancing the quality of samples, which was demonstrated by the decrease in the percentage of rejected samples. Conclusion Staff productivity increases when JCI standards are implemented. However, staff motivation is dependent on their involvement with management decisions and the smooth transition through change management, which ensures staff retention and therefore increase productivity.


| INTRODUCTION
Quality of care has transformed to become an essential element of healthcare service delivery, which caused decision makers in Health Care Organisations (HCOs) to seek methods to evaluate the level of care provided. Accreditation is a formal process in which an authorized body evaluates and assesses an organization's compliance with a set of pre-designed performance standards. 1 Healthcare leaders and top management bodies in HCOs consider accreditation as being an effective approach to improving the quality of care provided. Moreover, the process of accreditation is considered exhaustive and requires top management commitment as well as proper resource management, which includes staff involvement throughout the complete progression. This costly process is under a dilemma of whether the application of these pre-set standards is effective and how the accreditation, certification impacts the human talents at the HCO, mainly the staff of the Laboratory and Blood Bank.
The Joint Commission is known to be the "oldest health care accrediting body in the world". 2 Its standards aid HCOs toward improving the quality of care, as well as it responds to the extended needs of health care organizations. Health care organizations tend to improve their performance through accreditation by means of meeting the pre-set standards through policies, procedures, and protocols, whereby those are made in compliance with the targeted accreditation bodies recommendations. The process of policy development, protocol formulation, and implementation require proper resource allocation, as well as staff motivation and commitment.

| The impact of accreditation on the quality of diagnostic services provided by the laboratory
The definition of quality in health care varies with respect to the dimensions of the stakeholders, which includes and is not limited to patients, healthcare workers and third-party payers. To establish a simple and accurate definition of quality, we will refer to quality as a balance between what the organization plans and what the customer expects, which will be linked to how the organization delivers the services and how the customer perceives it. This will add sustainability and consistency into the loop, which can be achieved through standardization. The health care sector is controlled by several factors such as price, competitive advantage also affected by the market structure, publicity and mainly the quality of care provided. 3 Laboratories have developed three main pillars; quality, clinical effectiveness, and cost effectiveness. The main priority is the quality of services provided since it directly impacts the two others. Laboratories tend to improve quality through decreasing diagnostic errors, reducing turnaround times of tests performed and standardization of all laboratory procedures through policies, procedures, and protocols. Laboratories aim toward accreditation due to several factors, an example of which is competency demonstration which acts as a competitive advantage, improving quality of service, and satisfying managerial interests. Also, accreditation can be considered as a stimulant of continuous quality improvement, which keeps the quality system alive at the HCO. However, the accreditation process is considered a time and resource consuming activity, thus the dilemma lies between to accredit or not to accredit a Clinical Laboratory.

| The development of JCI accreditation in the clinical laboratory and blood bank
In 2010, the Joint Commission International (JCI) developed the Accreditation standard for clinical laboratories (second edition) which is derived from its general quality standards that provides hospital accreditation.
The significance of JCI accreditation lies within the development of quality management practices in hospital laboratories. The JCI accreditation combines a standard with its corresponding guideline, which defines the intent of each standard and the unique measurable elements of each requirement. Laboratory and Blood Bank standards fall beneath the Assessment of Patients (AOP) chapter, which includes all the diagnostic services provided by the hospital. Safety requirements are the most significant in this chapter, however, it is the only document that does not cover all the total Quality System Elements (QSE); whereby the information management aspect is not tackled. JCI standards do not give the Blood Bank and Transfusion services specific standards and guidelines, however, the process of organization and quality assurance is similar to that applied in the Clinical Laboratory. The importance of JCI accreditation in the Clinical Laboratory and Blood Bank lies within the standardization of processes and the importance of documentation to guarantee the tracking of services, minimizing errors and securing continuous quality and performance improvements.

| Change management through the JCI accreditation process
Change management is known to be the ability to redirect the processes, structures, and capabilities of an organization in response to external or internal alterations. 4 Implementing changes in health care is difficult since it requires the collaboration of people from different orientations. The process of JCI accreditation is subject to constant pressure to improve processes, methods and technologies at the Laboratory and Blood Bank. This will include and will not be limited to changes at the workforce level, methodology and automation, sectional organization, policies, procedures, and programs as well as excessive documentation. Quality control measures are subject to enormous resistance since they are culture dependent. The importance of sectional organization lies within optimization of Laboratory performance through reducing the Turn Around Time (TAT) of samples which improves the patient care in the organization. This is achieved by the unification of test procedure and maximizing automation. The main adjustment required by JCI standards is policy and procedure development, which ensures standardization. Managerial efforts in standardization have been successful in quality improvement, mainly in repetitive production and administrative processes. 5 Quality improvement through standardization frequently meets resistance, which delays the process of implementation and requires excessive managerial effort. Staff resistance to the changes enforced by JCI standards will interrupt the process of implementation and therefore accreditation. To ensure the proper implementation and to secure accreditation, Laboratory and Blood Bank management have to manage change in a way that sets a comfortable environment for staff. Subsequently, process standardization impacts different performance measures, and remarkable quality. 5 This implies that while developing policies and procedures, staff involvement will be crucial to guarantee compliance and thus appliance. "People are not always receptive to change". 4 Thus, it is the management's role to design the implementation of change. The process of implementation includes knowledge and education, methods, and techniques to facilitate the understanding and utilization of change. Employees resist change due to a variety of reasons, most importantly lack of understanding of the reasons to change an accustomed mechanism. Communication is the most fundamental tool to promote change, thus it is important to present the winning situation and confirm transparency. If the change will not under any terms secure a winning situation, the management should have the courage to withdraw without being vulnerable to pressure.

| Design and methodology
This study aimed at assessing the impact of JCI standards implementation on the Clinical Laboratory and Blood bank staff's productivity and motivation. It was conducted in one of the largest hospitals in Beirut.
It relies on the key performance indicators to assess the staff productivity before JCI standards implementation and throughout the process of implementation and development. An employee engagement survey was distributed and considered different variables present among the staff, including age, educational background, and working experience. A qualitative emergent approach was used, which was selected as the best approach to be primarily used in this study based on the interpretive epistemological paradigm. In an interpretive approach, qualitative researchers are known to study things in their "natural settings", by interpreting a phenomenon in terms of the way people bring meaning to them. 6 An interpretive approach was used to collect empirical data by interpreting the population's behavior, which is represented in this study by the questionnaire. The qualitative approach relies on the observation and examination of the targeted population which allows the researcher to derive the variables present. 7 The study is considered an emergent study that identified, explained, illustrated, and developed a model of staff motivation. In this type of study, the process of inquiry, supporting arguments, and questions of interest is developed after the launching of the study and during the process of data collection. The use of this design is due to the lack of situational control and inadequate understanding of the actual problem to be studied. Thus, the researcher relied on the social constructive paradigm, whereby the grounded theory (GT) is used to build the research model of staff motivation during the process of accreditation. The main purpose of GT is to integrate the qualitative and quantitative research methodologies in terms of developing action processes. 8 A questionnaire was built to assess staff motivation during standard implementation. Analysis of the questionnaire was made on Statistical Package for the Social Sciences (SPSS). Demographic descriptive data was extracted from this questionnaire. The aim of this study was to assess staff productivity and motivation during the process of JCI standards implementation, thus the study focused on staff experience, motivation, satisfaction, and productivity. For further analysis, the relationship between these variables was also studied. In order to assess the significance of the relationship between the above variables, a two-tailed chi-square test of significance was conducted on SPSS. Since the sample is relatively small (less than 30), Fisher exact test is used to determine the correlations between the qualita- To measure staff's productivity from another aspect, analysis of the incident report forms was conducted. Figure 3 shows the distribu- The relationship between staff experience and satisfaction level was assessed and represented in Table 1.
Satisfaction and extreme satisfaction were relatively exclusive to experienced staff, meaning with more than 25 years of experience.
Neutrality and minimal satisfaction were distributed among staff with 10 to 25 years of experience. However, the neutrality in satisfaction represented 50% of the population. Fisher exact test showed that our results are significant and H0 was rejected. This indicates that staff experience is dependent on satisfaction, since staff retention is built on satisfaction.
To study the impact of JCI standards implementation from another aspect, the relationship between staff's motivation during the process of standards implementation and staff experience level was monitored and represented in Table 2.
Neutrality was predominant in the assessed correlation between staff experience and motivation during the process of JCI standards implementation. However, this neutrality was generally distributed among staff with less than 25 years of experience. Highly motivated staff are predominantly experienced with more than 25 years of experience. This high motivation during the process of JCI standards implementation among staff with more than 25 years of experience is due to the conformity with new managerial decisions and changes, which can also be linked to their satisfaction level. On the other side, the neutrality among staff with less than 25 years of experience is related F I G U R E 2 Representation of the percentage of STAT tests exceeding the specified TAT along 6 months in the Clinical Chemistry, Hematology, and Parasitology F I G U R E 3 Representation of the number of rejected samples along a period of 16 months by the Nursing and Laboratory Phlebotomy teams to their resistance to change due to their relatively low satisfaction level. Fisher Exact test showed that a significant relationship exists between staff motivation during the process of JCI standards implementation and staff experience level, thus we reject H0.
Finally, Staff experience is dependent on satisfaction, since satisfaction is directly related to staff retention. Satisfied staff usually tends to accept managerial decisions which is reflected on their motivation toward improvement plans imposed by the management team.
Thus, experienced staff tend to be more satisfied and yet more motivated. This study was able to prove that JCI standard implementation increase staff productivity through organizational development, quality improvement, and control. However, its impact on staff satisfaction and motivation was minimal specially in staff with less than 25 years of experience which is due to several reasons that are manageable through proper change management.

| CONCLUSION
It is important to shed light on the fact that accreditation will not guarantee success and improvement in health care service delivery.
On the contrary, accreditation is to be used as an evaluation method of the standards, policies, and procedures implemented at the HCO.  When the gaps are identified, stakeholders will understand the need to change. Understanding change is different from wanting the change to happen. Stakeholders should have the will to change, this is T A B L E 1 Shows the staff satisfaction level according to their corresponding experience Note: A significant relationship exists between staff experience and satisfaction level. P value = 0.031 which is less than 0.05, which indicates the significance of the relationship between the two studied variables; staff satisfaction and experience level.
T A B L E 2 Shows the staff's motivation during the process of JCI standards implementation with respect to years of experience Change management is the most essential tool to ensure a successful process. This is achieved through the implementation of the ADKAR change management model will allow the organization to enhance staff motivation, which ensures staff retention and therefore increase productivity.

ACKNOWLEDGEMENT
We thank SGHUMC Laboratory and Blood Bank for providing access to the data and allowing its objective analysis. We also thank all the participants who consent to be part of this study. This output is part of a thesis study, which did not require funding from the organization or contributing authors.

CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.

AUTHOR CONTRIBUTIONS
Conceptualization: Rima Ramzi Abou Tarieh, Hanady Rafic Samaha. had full access to all the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.
Rima Ramzi Abou Tarieh affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

TRANSPARENCY STATEMENT
The authors confirm this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials.

ETHICS STATEMENT
The IRB/REC of University of Balamand/Saint Georges Hospital University Medical Center approved the use of SGHUMC data and under these terms the study was permitted.