Building quality culture through accreditation: a PRECEDE-guided exploration of leadership in clinical units

Overview

This study investigated perceptions of clinical management unit leaders regarding their roles in healthcare accreditation within a European public hospital. It sought to identify predisposing, enabling and reinforcing factors shaping leadership practices and the development of a quality-oriented organisational culture. Participants comprised six healthcare professionals acting as internal leads for accreditation projects under a regional health quality agency. The inquiry addressed conceptual alignment between accreditation and clinical practice, role clarity for internal leads, and the cultural and emotional dynamics accompanying accreditation processes.

Methods and approach

A qualitative hermeneutic design combined individual and group semi-structured interviews with participant observation. Data collection focused on experiences of internal leads responsible for accreditation implementation. Analysis employed Paul Ricoeur’s interpretative framework, using the PRECEDE model to categorise findings into predisposing, enabling and reinforcing factors that influence leadership and cultural change. Analytical procedures emphasised iterative interpretation of narrative data to reveal latent meanings and organisational dynamics.

Results

Three principal themes emerged. First, conceptual tensions: participants reported ambiguities between accreditation imperatives and existing quality culture, including misalignment of accreditation language with clinical and managerial realities. Second, leadership as collective and emotionally demanding: leadership was enacted as distributed work requiring emotional labour, negotiation of responsibilities and sustained team engagement, with internal leads experiencing role overload and insufficient role definition. Third, accreditation as dual-faceted process: accreditation produced concrete structural and procedural improvements while also functioning as an emotional and symbolic reinforcer that bolstered collective motivation and legitimised quality initiatives.

Implications

Organisational policy should clarify the internal lead role, invest in targeted leadership development and allocate sustained institutional resources to translate accreditation standards into clinically meaningful practices. Accreditation frameworks warrant redesign to better reflect the operational and managerial constraints of clinical units, reducing semantic and procedural misalignment. Future research should examine intersecting dimensions such as gender dynamics in leadership during accreditation and evaluate longitudinal impacts of accreditation-driven changes on organisational culture and measurable quality outcomes.