Table 2 . Potential downsides of an external healthcare evaluation program .

Downsides	Explanation
Mission deviation	Deviation of hospitals from their main mission, namely, treating patients
Resource diversion	Diverting hospital resources away from strategies aimed directly at addressing the quality and safety issues of services
Workload	Creating extra burden of work for hospitals creating stress and anxiety for their staff
Costly	Incurring undue cost on hospitals
Discouragement	Disappointing and discouraging the hospitals from attempts to improve their own functionality following an unsatisfactory score in their prior accreditation
Routinization and Bureaucratization	No thinking of innovation, stuck in the requirements imposed by PMSs to do activities in preset ways
Program Incongruence	Not fitting well with other quality-improvement activities already running in the hospitals such as ISO or EFQM
Judgmental nature	Over-reliance on value judgment of the surveyors in allocating scores to standards

PMSs: Performance Measurement Systems; ISO: International Organization for Standardization; EFQM: European Foundation for Quality Managem