Developing a Readiness Model for Community Hospitals Achieving Healthcare Accreditation (HA) through Participatory Action Research: A Case Study of Mahasarakham Provincial Health Network

Abstract

Purposes: To analyze the current situation, develop, implement, and evaluate a readiness development model for community hospitals seeking Healthcare Accreditation (HA) within the Maha Sarakham Provincial Health Network.

Study design: Mutual Collaborative Action Research.

Materials and Methods: The primary informants consisted of a Coaching and Mentoring team from Maha Sarakham Hospital and 15 Quality Coordinators. The study was conducted in phases: a situational analysis phase (n=10), a service system development phase (n=30), and a development participation phase (n=60). Data were collected using in-depth interviews, HA readiness assessment forms, self-assessment scales, observation records, and reflective forms. Quantitative data were analyzed using frequency, percentage, mean, and standard deviation, while qualitative data underwent content analysis.

Main finding: 1) Situational Analysis: Identified challenges in four key dimensions: human resources and knowledge management; work systems and processes; support mechanisms and networking; and leadership and organizational culture. 2) The Readiness Model: The developed model comprises four pivotal steps: establishing network synergy and collaboration; driving quality through the IQV (Improvement, Quality, Value) process; integrating the four dimensions of the development pillars; and achieving strategic outcomes, and 3) Implementation Outcomes: Post-development evaluation revealed that overall organizational management reached the highest level = 4.53, SD. = 0.53). The level of learning through the Quality Learning Network (QLN) process was rated at a high level (Mean = 4.37, SD. = 0.27). Consequently, both Kud Rang Hospital and Chuen Chom Hospital successfully achieved Step 1 Healthcare Accreditation (HA) in 2025.

Conclusion and Recommendations: The success of these two hospitals signifies the effective cultivation of a safety culture within the organizations. It is recommended that the hospitals maintain this developmental momentum by enhancing work system integration and fostering intensive staff participation to ensure sustainable quality improvements.