Sustainable hospital accreditation in low- and middle-income countries: lessons for global stakeholders from Sri Lanka's discontinued national program

The Sri Lankan Hospital Accreditation Program, initiated in 2015 and discontinued in 2019, provides a unique opportunity for global accreditation stakeholders to learn from the failure of a hospital accreditation program (HAP). The discontinuation was due to multiple meso- and micro-level factors, resulting in inadequate project management and limited integration and coordination of accreditation program elements.

Quality and safety management (QSM) in hospitals ensures that health services are delivered in a safe, timely, efficient, effective, equitable and patient-centred manner (Committee on Quality of Health Care in America, 2001). Hospital accreditation programs (HAPs) are imperative to achieve QSM systematically through maintaining and continuously improving healthcare and organisational standards (Kiran et al., 2024).

HAPs involve an independent, external body evaluating an organisation's performance against predefined standards via a team of trained assessors. They are increasingly used in low- and middle-income countries (LMICs), which experience the largest global burden of poor quality and unsafe healthcare (World Health Organization, 2024). Many HAPs in LMICs have been discontinued, having consumed significant resources and attention (Dharmagunawardene et al., 2025). Contributing factors include insufficient resources, non-alignment of HAPs with regulatory and governance architecture, and limited patient safety culture (Dharmagunawardene et al., 2025; Mansour et al., 2020).

Research on contributors to the emergence, progression, and eventual discontinuation of HAPs in LMICs is limited. This study, focusing on the Sri Lankan Hospital Accreditation Program (SLHAP), aimed to address this gap. Most research on this topic involves description or evaluation of successful programs, rather than critical analysis of programs that are viewed as failures, making this study a unique contribution to the literature. The SLHAP was initiated in 2015 by the Directorate of Healthcare Quality and Safety (DHQS), Ministry of Health (MoH) (Directorate of Healthcare Quality and Safety, 2024). The initiative was discontinued in 2019 (Dharmagunawardene et al., 2024; Karandagoda, 2023) (Figure 1). This study explores the key drivers that contributed to the emergence, progression and discontinuation of the SLHAP. Lessons from this experience are distilled as guidance for other LMICs embarking on sustainable accreditation reforms.

An interpretivist case study was employed to capture the lived experiences of purposively selected participants (Palinkas et al., 2015), who represented six groups directly involved in establishing the SLHAP. Initially, four groups were identified, and an additional two groups were recognised through snowball sampling (Table 1) (Naderifar et al., 2017).

The interview guide was structured using a modification of the ACES–GLEAM framework, which was developed in a published scoping review (Dharmagunawardene et al., 2025). The Framework outlines core components of a HAP trajectory (Figure 2). The interview guide was checked for face validity and pilot-tested with non-participating Sri Lankan healthcare administrators. During April 2024, semi-structured interviews were conducted in English.

Snowball sampling, combined with iterative data analysis, continued through to data saturation (Saunders et al., 2018). After developing a codebook (Supplementary File I), meaningful segments of text were extracted from transcripts (Saunders et al., 2023) using Lumivero's NVivo qualitative data analysis software (Jackson and Bazeley, 2019). Data analysis of 10% of coded text segments was reviewed independently by team members for validation (Saunders et al., 2023).

When presenting the results, the ACES–GLEAM Framework, which guided data collection, was reorganised into three analytical categories as factors contributing to emergence, progression and discontinuation. Antecedent influences, governance and legislation domains were categorised as factors of emergence. Hindering contextual factors were classified with the factors of discontinuation. The remaining domains (enablers, standards, surveyors, stimulants, surveys and survey execution with assessment and monitoring) were broadly classified as factors contributing to the progression (Figure 3).

Ethics approval was granted by the Human Research Ethics Committee of [recognised university, to be included after anonymised peer review] (Ethics Approval Number 6951).

The results were categorised into the stages of emergence, progression and discontinuity of SLHAP, and the trajectory based on the expressions of the study participants is illustrated in Figure 1. According to this figure, the SLHAP was a continuation of a long-standing quality assurance program that was initiated in 1989. The SLHAP was initiated in 2015, with the establishment of the National Council on Accreditation of Healthcare Services (NCA) as the steering committee, and the DHQS as the implementation body. Context-specific standards development was initiated in 2016 with technical assistance from the Australian Council on Healthcare Standards (ACHS), which was not completed by the time of surveyor training. Then, the surveyor training was conducted in 2018 with the technical assistance of ACHS, using ACHS Equip6 standards, and 12 Sri Lankan surveyors were selected. These surveyors and ACHS surveyors conducted a gap analysis in six Sri Lankan pilot hospitals with three objectives: (1) to provide experiential training for the Sri Lankan surveyors, (2) to assess the feasibility of assessing public hospitals using ACHS standards and (3) to evaluate the existing gaps in public hospitals. Despite creating awareness and enthusiasm among a few selected stakeholders, the SLHAP was discontinued in 2019 due to a myriad of factors, without progressing to a stage of a fully-developed HAP with formally accredited hospitals or changes in accreditation governance.

The contributory factors for emergence, progression and discontinuation, which are classified according to the ACES–GLEAM framework, are illustrated in Figure 3.

Four factors shaped the emergence of the SLHAP: leadership from MoH policy officials, the need to enhance safety and quality capabilities across the system, emerging capabilities of private health organisations, and the opportunity for international assistance.

Participants reported that the SLHAP was initiated due to the MoH policy officials' leadership. Critically, they were positioned to introduce the HAP, following their exposure to international HAPs.

The policy officials identified the need to uplift a long-standing hospital quality program by establishing the SLHAP. The SLHAP’s emergence was further fuelled by increasing concerns regarding medical litigation, the broader context of socio-economic transformation, and increased prosperity during the country's immediate post-civil-war period.

The motivation of policy officials was also influenced by their awareness of local, well-resourced private hospitals’ voluntary participation in international HAPs as a measure to promote medical tourism. The SLHAP presented a strategy to enhance the public sector’s capabilities in improving quality and safety.

International bodies shaped the emergence of the SLHAP externally through this networking. The DHQS coordinated and collaborated with international agencies to initiate the SLHAP, including ACHS for technical assistance and the World Health Organization (WHO) for financial assistance.

The SLHAP progressed from an idea into reality through three interrelated actions. First, a legislative and policy governance system was established to provide context for the program. At the same time, program components were developed, including accreditation standards, surveyor recruitment and training, survey management (logistics and communication) and survey execution. These mechanisms were facilitated by an accreditation-quality improvement culture consisting of staff competency and organisational culture-related enablers.

Two policy officials expressed that the National Policy on Health Care Quality and Safety, published in 2015, was a significant enabler of program development and progression. The governance mechanisms were financially facilitated through funding by international donor agencies. ACHS facilitated implementation by training senior officials and local surveyors, developing standards and conducting compliance gap analyses.

The DHQS engaged in a multistakeholder collaborative process to produce the SLHAP standards by adapting ACHS standards to the Sri Lankan context. DHQS policy officials reviewed three international standards to assess their local feasibility and applicability. The ACHS standards were selected for use in the SLHAP. The ACHS was consulted to educate Sri Lankan stakeholders about the accreditation program and associated processes. Following training, the ACHS standards were reviewed by local experts.

Participants reported that the initial trainee surveyor cohort comprised 12 representatives of professional colleges or those involved with the DHQS. Recruiting Sri Lankan health staff from diverse specialities empowered local change agents and diffused knowledge and capabilities across the health system. ACHS surveyors were engaged in the initial induction and subsequent experiential training (during gap analysis). Surveyors and MoH officials viewed training as comprehensive and interactive, enabling the acquisition of required competencies to conduct valid, credible assessments.

Participants stated that the SLHAP's progression was grounded in effective survey management activities (communication, coordination and logistics arrangements) with the six public hospitals. These hospitals were selected for gap analysis (survey execution) as a pilot project. Activities were coordinated by DHQS at the national level and by the hospital quality management units (QMUs).

A survey execution, in the form of a standards compliance gap analysis, was conducted to assess the feasibility and applicability of ACHS standards in the Sri Lankan context. The task had the added benefits of further training for surveyors. Surveys were conducted by both Sri Lankan and ACHS surveyors, with stakeholders reporting that the involvement of ACHS surveyors promoted confidence, reliability of assessment and effective communication.

Participants perceived that the mix of local and international surveyors promoted knowledge sharing, attention to local context and credibility. The combination of surveyors enhanced a culture of safety and quality through improved health staff competencies and developed a sustainable, competent local surveyor workforce.

Almost all participants, particularly ACHS surveyors, commended health staff for their enthusiasm, commitment, keenness to learn and engagement with the quality improvement process. Participants commended the interest, commitment, support and collaboration of the leaders of the MoH, DHQS and hospital administrators. These organisational culture aspects, with local capacity development, contributed to the initial successful progression.

The discontinuation of SLHAP resulted from the combination of barriers linked to governance and leadership, HAP components, contextual, personnel and cultural issues. They were related to resources, skills and competencies, as well as organisational culture-related barriers.

Stakeholders reported that governance and leadership-related constraints were a major impediment to SLHAP. This included a lack of shared decision-making, limited multi-stakeholder involvement, poor communication between the MoH and ACHS, and regular deviation from previously agreed-upon project management plans, contributing to discontinuation.

Leadership-related problems, such as frequent changes, including the unexpected death of the Director of Quality, have reduced institutional memory. The lack of information and knowledge transfer during turnover resulted in a decline in understanding and process competencies. As a result, inconsistencies and ambiguities arose in the overall guidance.

Participants reported that while adapting ACHS standards to the local context was agreed upon, no adaptation ultimately occurred. This was due to the later decision of MoH policy officials, who independently considered ACHS standards appropriate. ACHS and local surveyors held concerns about standards not aligning with local system constraints and context. Stakeholders noted that the version of the ACHS standards underwent a change due to the lengthy project period, rendering the original training and initial gap analysis less relevant. The failure to adapt the standards was viewed as a major reason for discontinuation, representing a lack of multi-stakeholder engagement and shared decision-making.

Despite a strong belief in the quality of surveyor training, stakeholders reported concerns about surveyor recruitment. These concerns stemmed from not having or adhering to specific recruitment criteria, limited representation of all professional categories, a lack of preparation or awareness about accreditation prior to surveyor recruitment and poor engagement with MoH activities. Poorly planned recruitment and subsequent limited engagement resulted in a lack of collaboration between the MoH and trained surveyors.

Sri Lankan surveyors and hospital administrators reported inadequate pre-survey communication strategies, resulting in minimal awareness among health staff about the standards and assessment processes, as well as the purpose of the gap analysis. Inadequate preparation of hospitals due to a lack of time before program implementation was highlighted by participants outside the MoH. Similarly, despite DHQS officials’ mention of training programs for hospital staff, only one hospital administrator reported receiving any training. One senior MoH officer indicated that they wanted to assess the situation during the gap analysis without prior information given to the hospitals. Overall, these differences in statements between participants revealed no standard process of communicating standards to the pilot settings of gap analysis.

The ACHS and local surveyors mentioned multiple barriers to survey execution, such as contextual mismatches, resource limitations within hospitals and problems in the hospitals (overcrowding and ongoing construction work), to implement standards.

Hospital administrators expressed dissatisfaction with the HAP because they received no feedback or a final report. MoH policy officials received a final report almost one year after completing the surveys, but dissemination was limited to top-level policy officials. Nevertheless, most participants outside the MoH were unaware of the program assessment, monitoring or evaluation, or the availability of the gap analysis reports. This inadequate feedback led to limited learning and the disengagement of frontline stakeholders.

Program resource constraints, such as inadequate resources, lack of equipment and poor infrastructure, were highlighted by participants, except for higher MoH policy officials. The main reported financial barriers were the high cost of accreditation, the need for costly investments for related institutional changes and the lack of prioritisation of allocations amidst other demands. The rapid turnover of staff involved in quality and safety activities was the primary reported human resource-related barrier.

Stakeholders reported that staff turnover led to competency-related constraints. Inadequate accreditation skills and knowledge, and quality and safety practices, existed among middle-level managers. Front-line hospital staff's lack of education, training and awareness on accreditation-related topics, in addition to a lack of expertise at the DHQS, were reported by participants. As a result, middle-level managers were unable to ensure staff engagement and support for accreditation, which contributed to its discontinuation.

Participants stated there was a broad group of organisational culture- or perception-related barriers, which included negative perceptions towards accreditation, poor perceptions of multi-stakeholder engagement and negative perceptions of teamwork. Poor quality culture-related perceptions were reported, such as “afraid of audits”, “fault-finding missions” and “assessments lead to punishment”.

Negative perceptions among clinicians and policymakers included less support for quality, safety and accreditation-related activities, and more prioritisation of clinical work volume. Other identified cultural barriers to sustainability among leaders included: unnecessary influences from the hierarchy, working based on personal agendas, not involving all leaders in the hierarchy and trying to pursue accreditation as an isolated initiative.

This study explored key drivers that contributed to the emergence, progression, and discontinuation of the SLHAP. The study’s strength lies in its critical examination of a failed (rather than successful) HAP, as well as the breadth of participants from diverse backgrounds directly involved in the SLHAP, which elicits rich and in-depth information that can guide the accreditation activities of stakeholders in other LMICs.

The limited prior research on this topic has attributed the failure of HAPs in LMICs to resource scarcity and weak pre-existing infrastructure (Bukonda et al., 2003; Dharmagunawardene et al., 2025; Mansour et al., 2020, 2021). Conversely, this case study provides a counterexample, making a novel contribution to the literature. Despite having pre-existing quality and safety structures, donor funding and technical support, the Sri Lankan HAP still failed to be sustained. This case study revealed that the main factors impeding implementation were related to project management and governance dynamics, including leadership turnover, inadequate adaptation of standards and limited feedback, which reduced stakeholder engagement. These factors may be present in other examples of failed HAPs in LMICs, but have remained invisible within the existing literature. This paper has distilled these unique findings and translated them into a set of concrete, transferable HAP design principles for donor agencies, ministries of health and accreditation bodies to maximise the chances of implementation success and sustainability.

Similar to the SLHAP, leadership turnovers are frequently highlighted as contributory factors for the discontinuation of HAPs in LMICs (Dharmagunawardene et al., 2025; Mansour et al., 2021). In the SLHAP, this was further exacerbated by the non-transfer of institutional memory. A recent systematic review examining sustainability in 124 healthcare improvement programs highlighted that the key barriers to longevity were leadership and related support, training and supervision, consistent staffing and low turnover (Zurynski et al., 2023).

Leadership and governance dynamics in SLHAP led to delays in adapting and communicating standards. This has led to limited competency and awareness of accreditation among health staff, resulting in minimal staff engagement. Staff competencies were found to be an important barrier to sustainability because they impact implementation through facilitation of continuous quality improvement and engagement (Alhawajreh et al., 2023). Well-established staff training programs are a feature of ongoing accreditation programs in Jordan and SafeCare (Arabji, 2013; Spieker, 2020). Staff competencies and education are noted as foundational pillars for organisational patient safety programs (International Society for Quality in Health Care, 2025) and are also imperative for enhancing staff engagement. Accordingly, staff engagement is another critical factor for the sustainability of HAPs (Greenfield et al., 2011; Hinchcliff et al., 2013a; Hussein et al., 2025).

Delays in adaptation and communication standards, and limited staff awareness, competencies and engagement, were all due to the sudden and unplanned changes experienced by the SLHAP. These changes were largely a result of project management constraints in scope, time, quality, communication, stakeholders and human resources (Freire et al., 2016; PMI - Project Management Institute, 2012), which have not been highlighted in contemporary accreditation literature or existing guidelines. Existing guidelines from the International Society for Quality in Health Care (ISQua), the WHO, and other organisations focus on the technical aspects of program development without considering programs as long-term, complex projects (International Society for Quality in Health Care, 2018; World Health Organization, 2022). Nevertheless, program complexity, inadequate planning and group design were noted in the discontinuation of healthcare improvement programs (Zurynski et al., 2023).

As a further point of contrast, financial and human resources and previously weakened structures and systems were not reported as prominent barriers for the discontinuation of SLHAP, similar to other LMIC programs (Bukonda et al., 2003; Dharmagunawardene et al., 2025; Mansour et al., 2020, 2021). Despite SLHAP discontinuation, some HAPs in LMICs have sustained operations and subsequently obtained ISQua recognition (Arabji, 2013; David and Valas, 2017; Spieker, 2020). The continuation of these HAPs has been reportedly due to sustained positive driving forces, such as leadership support, robust standards development adapted to the local context, ensuring competencies of health staff on accreditation, reliable surveyor training programs (Dharmagunawardene et al., 2025; Mansour et al., 2020), supportive safety and quality policies and strategies (Alhawajreh et al., 2023; Hinchcliff et al., 2013b; Mansour et al., 2020), and incentives mainly linked to insurance systems (Mansour et al., 2021).

The study revealed and confirmed in the literature that emergence, progression, and (dis)continuation result from a complex interplay of multiple factors. This result reflects the complex dynamic system of the health sector, regardless of country setting, and the challenge of achieving positive, lasting change in safety and quality dimensions (Zurynski et al., 2023).

Continuation or discontinuation of HAPs are unique trajectories specific to each context but shaped by common features: leadership, communication, broad engagement of health professionals, education and training, health system and organisational resilience, and safety and quality cultures. A set of evidence-informed guidelines aligned with the key results is illustrated in Figure 3.

Effective and consistent project management significantly contributes to the implementation and outcomes of HAP. Program sustainability, including institutional memory, handover protocols for leaders, predetermined program and standard updates, and embedded medium-to long-term program evaluations, needs to be built into the initial design. The focus of internal stakeholders should be on formulating a long-term plan for establishing HAPs, incorporating the aforementioned strategies.

Formulating long-term plans should target the achievement of individual sub-components in a gradual and stepwise manner, including training for health staff and leaders, surveyor training and standards development. Similarly, external stakeholders should focus on facilitating the above individual sub-components technically and financially as specific entities, in an overall continuum of the HAP establishment pathway.

Finally, education and awareness of staff and leaders on accreditation concepts need to be conducted as a key engagement endeavour. Out of this cohort, local champions and surveyors can be recruited to advocate for, and participate in, the implementation of HAPs.

There are three main study limitations: (1) the study focused on one HAP in one country, (2) recall bias among participants and (3) participants were stakeholders involved in SLHAP, who may be biased and conceal contributing factors. However, including participants from diverse hierarchical levels and stakeholder groups minimised this risk.

Understanding key drivers contributing to the emergence, progression and discontinuation of HAPs in LMICs can help improve safety and quality processes and outcomes. Success and failure result from a complex interplay of multiple factors, each countering or reinforcing each other, in a dynamic process unique to a specific setting. SLHAP provides a blend of unique and common factors that is imperative for the success and sustainability of HAPs in LMICs. Despite a certain degree of resource constraints similar to those of other LMICs, Sri Lanka had a relatively good health infrastructure and financial resources for accreditation. The discontinuation of SLHAP was uniquely and prominently linked with the issues of project management and planning, leading to incoordination between HAP elements during establishment, and this factor was limitedly explored in previous literature. Moreover, similar to other LMICs, the discontinuation of SLHAP was linked with leadership turnover, poor engagement and limited competencies of stakeholders.

Therefore, as illustrated in Figure 3, sustained leadership, coordinated and continuous local multi-stakeholder engagement and long-term planning are key to success. Additionally, a series of internal and externally integrated tasks is required to achieve individual HAP elements, recognising that the establishment of HAPs is a highly complex intervention. These aforementioned elements should be integrated into an effective project management trajectory to maximise the chances of implementation success and sustainability of HAPs.

The authors would like to acknowledge the administrative approval granted for the study by the Director General of Health Services and the Deputy Director General – Medical Services, Ministry of Health, Sri Lanka. In addition, the contributions of all the key informants who shared their insights without any remuneration are gratefully acknowledged. This study was completed while the first author held PhD scholarships that were funded by Griffith University and Queensland University of Technology, Australia.

The supplementary material for this article can be found online.