Interface between accreditation and patient safety: nursing team perspectives

ABSTRACT

Objective

To understand the relationship between accreditation and patient safety from the perspective of the nursing team.

Method

A descriptive-exploratory study implementing a qualitative approach. It was developed with nursing workers from two Intensive Care Units in a hospital certified in excellence by Brazilian accreditation. The participants responded to individual semi-structured interviews guided by the question: “Tell me about the relationship between accreditation and patient safety in this hospital and unit”. The corpus was transcribed in full, and the thematic content analysis technique was used.

Results

There were 14 professionals interviewed. There are several specific improvements in patient safety mediated by accreditation between the two emerging categories. The workers reported that at times the advances in safe care are transversally visible to the certification/maintenance of accreditation visit, and at times they point to safety as something independent of the quality seal.

Conclusion

It was concluded that the investigated relationship was shown to be both dependent, as accreditation is a bridge for specific improvements, as well as independent, since patient safety goes beyond the certification process itself. In this context, criticality was revealed among nursing workers.

Hospital Accreditation; Patient Safety; Quality Management; Nursing, Team; Intensive Care Units

RESUMO

Objetivo

Apreender a relação entre acreditação e segurança do paciente, na perspectiva da equipe de enfermagem.

Método

Estudo descritivo-exploratório, de natureza qualitativa. Foi desenvolvido com trabalhadores de enfermagem de duas Unidades de Terapia Intensiva de um hospital certificado em excelência pela acreditação brasileira. Os participantes responderam a entrevistas individuais semiestruturadas, norteadas pela questão: “Fale-me sobre a relação entre acreditação e segurança do paciente neste hospital e unidade”. Ao corpus transcrito na íntegra, empregou-se análise de conteúdo temática.

Resultados

Foram entrevistados 14 profissionais. Entre as duas categorias que emergiram, relaciona-se diversas melhorias pontuais na segurança do paciente mediadas pela acreditação. Os trabalhadores referem que: ora os avanços no cuidado seguro são visíveis transversalmente à visita de certificação/manutenção da acreditação, ora pontuam a segurança como algo independente do selo de qualidade.

Conclusão

Concluiu-se que a relação investigada tanto se mostrou como dependente, pois a acreditação é ponte para melhorias pontuais, como independente, já que a segurança do paciente transpõe o processo de certificação em si. Nesse contexto, revelou-se criticidade entre os trabalhadores de enfermagem.

Acreditação Hospitalar; Segurança do Paciente; Gestão da Qualidade; Equipe de Enfermagem; Unidades de Terapia Intensiva

RESUMEN

Objetivo

Aprender la relación entre acreditación y seguridad del paciente, en la perspectiva del equipo de enfermería.

Método

Estudio descriptivo-exploratorio, de naturaleza cualitativa. Fue desarrollado con trabajadores de enfermería de dos Unidades de Terapia Intensiva de uno hospital certificado en excelencia por la acreditación brasileña. Los participantes responderán a entrevistas individuales semiestructuradas, guiadas por la cuestión: “Habla-me acerca de la relación entre acreditación y seguridad del paciente en esto hospital y unidad”. Al corpus transcrito en su integridad, utilizó el análisis del contenido temático.

Resultados

Fueron entrevistados 14 profesionales. Entre las dos categorías que emergieran, relaciona se diversas mejoras puntuales en la seguridad de lo paciente mediadas por la acreditación. Los trabajadores refieren que: ora los avanzos en el cuidado seguro es visible transversalmente a la visita de la certificación/manutención de la acreditación, ora puntúan la seguridad como algo independiente del sello de calidad.

Conclusión

Se concluye, pues la acreditación es puente para mejoras puntuales, como independiente, ya que la seguridad de lo paciente transpone el proceso de certificación en sí mismo. En esto contexto, revela se criticidad entre los trabajadores de enfermería.

Acreditación de Hospitales; Seguridad del Paciente; Gestión de la Calidad; Grupo de Enfermería; Unidades de Cuidados Intensivos

INTRODUCTION

Quality in the health sector is an even more evident challenge for managers and professionals who produce services, as this area of human production is essentially distinguished from other service provision sectors by the peculiar characteristic of production and consumption of the “product”, the assistance/care, which are concomitant with each other(¹).

In recognizing the peculiarity of quality in health, defining it properly is still another challenge, since once it is legitimized by consumers/users, the conceptualization of what is meant by qualified care mainly tends to be social and historically changeable(¹-²). Despite this, the optimized use of available resources; greater satisfaction of internal and external customers; and a reduction in risks associated with care have been accepted as the aegis of understanding quality in health(²-³).

By accepting that the risk or harmful potential is inherent to care production, patient safety emerges as one of the pillars which underlies quality itself, meaning that safety is not synonymous with quality, but it is undoubtedly one of its most important critical/basic points(⁴). Thus, the World Health Organization lists the following basic precepts for qualified care: effectiveness, efficiency, accessibility, acceptability, equity; and more recently, safety(⁵).

Despite being a desirable asset which involves the systemic organizational culture in its favor, patient safety needs to be made possible by concise, proactive, shared, systemic and systematic management practices, such as: planning, continuing education, risk management, implementation of care protocols, and mainly cyclical assessment of the implemented strategies, followed by (re)planning(⁶).

In the context of health assessment, accreditation has emerged worldwide as a management system essentially based on assessment activities which are external to the participating organizations, being very well adapted to the unique reality of the health area(⁷-⁸).

The essence of accreditation is based on a comparison of the institutional reality, evaluated externally and periodically in the light of previously defined quality standards, which are determined in a clear and standardized manner by the accrediting methodology adhered to by each country, which, in the case of Brazil, is represented by the National Accreditation Organization (NAO), in addition to others from North American realities such as the International Joint Commission, Canadian Accreditation Council, and National Integrated Accreditation for Healthcare Organizations(⁷). Certification is a very welcome product of accreditation, however, in theory it is not its priority purpose, but rather the continuous improvement, systemic continuous education for quality culture and the use of systematic tools(⁹).

Accreditation is a quality management system which tends to be conducted through establishing criteria, standards and indicators, meaning that it leverages the strategic vision of the institutions, including aspects of marketing and managerial growth in various organizational spheres(⁸,¹⁰-¹¹). In the accreditation methodology mediated by the NAO, the criteria of the first (of three) certification levels essentially correspond to practices which are focused on patient safety(¹²).

Despite the “evident” relationship between accreditation and patient safety, since the second is one of the central focuses of the quality management system in question, studies which enable better/greater knowledge about the effects of accreditation in different aspects have been recommended by recently published research, and not only in Brazil(⁷-⁸,¹⁰,¹³-¹⁵), which means investigating the potentials of this quality certification process, which undoubtedly includes patient safety, still denotes novelty and mainly necessity. Furthermore, even if this gap in knowledge exists, one is based on the empirical principle that there is some relationship, whether positive or not, between the researched phenomena.

Considering that the nursing team is a protagonist in actions which favor patient (un)safety due to their fundamental and uninterrupted participation in the care processes, especially in the hospital environment, the importance of investigating the issue previously mentioned with a focus on this population emerges. Therefore, this study is guided by the question: What are the perspectives of the nursing team on the relationship between accreditation and patient safety? Therefore, the objective was to understand the relationship between accreditation and patient safety from the perspective of the nursing team.

METHOD

STUDY DESIGN

A qualitative, descriptive-exploratory study.

SCENARIO

The research site was a general hospital located in the state of Paraná, Brazil, being a holder of the accreditation certificate.

SELECTION CRITERIA

The hospital selection was made by searching the NAO website for a general hospital with intensive care beds, possessing a seal for the highest certification level from NAO (Accredited with Excellence), with the quality seal still having validity, and located in the state of Paraná, Brazil.

The criteria definition for certification in excellence was intentional, as it is understood that workers in this type of organization could have greater knowledge about the relationship between accreditation and patient safety. The presence of an Intensive Care Unit (ICU) in the organization was foreseen with the clear knowledge that these sectors impose a high risk to patient safety. On the other hand, geographical delimitation of the state of Paraná was due to increasing the study feasibility, as it would be based in the same state.

The research population comprised nursing professionals assigned to the two ICUs for adults in the accredited hospital, one of which is general care and the other specializes in coronary care. The sample (n=14) was composed through convenience approach by workers who met the only eligibility criteria, regardless of whether a nurse or a mid-level professional, namely: working at the unit for at least six months. This criterion was defined so that the worker had conditions/support to respond to the study purpose.

DATA COLLECTION

Data collection was carried out in June 2017 by applying a form for determining the sociodemographic and labor characteristics of the participants, and a semi-structured interview which was recorded with the consent of nursing workers, being guided by the following question: “Tell me about the relationship between accreditation and patient safety in this hospital and unit”. The number of interviews was defined when the testimonies became successively repetitive, meaning that there was data saturation. All data extracted from the testimonies were fully transcribed in digital media, and subsequently printed.

DATA ANALYSIS AND PROCESSING

The Content Analysis technique in the Thematic modality was carried out on the empirical corpus of the data in print, respecting the pre-analysis, material exploration and data interpretation stages(¹⁶).

The pre-analysis comprised identifying the central ideas of the statements which signify the key points of their speeches, duly highlighted by the researcher through a floating (primary) reading of the empirical material(¹⁶). The exploration of empirical material consisted of repeated readings of the corpus, constituting a procedure which highlighted the previously mentioned central ideas and gave light to the nuclei of meaning, implying the core of meanings emitted by the interviewees, which come from in-depth reading of the content reported by the interviewees(¹⁶).

Finally, the data were (re)interpreted through an analysis of the nuclei of meaning, giving systematic content to the categories arising from the previous steps, which means nominally condensing the semantic content reported by the participants(¹⁶).

In the presentation of the results, the excerpts/quotations/verbatim from the statements extracted from the analyzed interviews were edited to standardized language, however without changing the meaning of the statements. Terms in square brackets were added when the reader needed a better understanding of the testimony. Interviewees were identified by the letter “I”, followed by an Arabic number from 1 to 14 according to the chronological order of the interviews.

ETHICAL ASPECTS

All ethical principles of Resolution no. 466/12 of the National Health Council, which governs research with human beings, were fully complied with, which includes the proper distribution, reading and signature in two copies of equal content of the Free and Informed Consent Form by all participants. The Research Project which fostered this study was submitted and appreciated by the Institutionalized Ethics Committee through an Opinion no. 1.788.249/2016.

RESULTS

The selected hospital was characterized as medium-sized, with beds available to the Unified Health System, located in the interior of Paraná, with accreditation certification at the level of excellence (“Level 3” – NAO) since 2014.

From the 14 professionals interviewed, only one was a man. Twelve professionals were married, and two were single. The distribution between nurses and nursing technicians was equal (seven in each professional category). The average age of workers was 36 years (± 8.6).

Thematic content analysis of the interviews revealed two categories: (1) Immediate improvements in patient safety arising from hospital accreditation; and (2) Patient safety: an asset which is dependent on or independent of accreditation certification?

IMMEDIATE IMPROVEMENTS IN PATIENT SAFETY ARISING FROM HOSPITAL ACCREDITATION

Nursing workers recognized accreditation as a means of boosting/increasing safe care, particularly through the rational use of protocols and strategies for healthcare safety, which were demanded for accreditation:

(...) from the time the patient arrives, they receive identification, both the bracelet and the nameplate on the bed. The colored ribbons, each of which represents one thing. The risk of falling for the patient (...) We had a change of beds recently. All the beds have good side rails, they are electric beds (I6).

We didn’t identify the patient in the past. Today, high-risk medications have already been identified, they arrive with a very large label, in red, to see that it’s dangerous (...) The protocol bracelets: chest pain, people who have fistula, or have pressure injury (...) (I8).

I think that’s what it’s all about. Accreditation, it is to humanize this care, the treatment, and patient safety. I see that accreditation is to really focus on the patient, on their safety. To control infection and these things (...) (I10).

Several protocols and/or safety measures made possible (required) by accreditation are clearly named, reinforcing the management system on the agenda as a foundation for occasional improvements in safe care:

Patient identification is a requirement for accreditation. It prevents various adverse events, and the practice of never treating a patient and applying a medication without double checking (...) The safe surgery part is also a protocol for patient safety, which means following all steps of safe surgery (...) VAP [ventilation-associated pneumonia] prevention, which is to maintain the bed elevated at 45º, and perform aspiration. We have care procedures which we have to follow to avoid VAP (...) Accreditation fosters this (...) This is accreditation. They see it, in a way, as an inspection, but it is with the intention of always giving tips for the hospital to improve (I12).

Furthermore, they also list some improvements in patient safety connected to the accreditation of the employing hospital:

We observed some changes, mainly in relation to medication. There were many changes which helped, created barriers [of safety], and even in the way of working with the patient (I4).

(...) Sepsis protocol. Once entered the sepsis protocol, you have to collect all the routine exams and start the antibiotics (I7).

All working protocols create interactions between processes. I think it’s really great, and we try to follow them. And there are the [adverse] events. Based on events, there are flaws, we try to see interactions, non-conformities (...) It [accreditation] aims at improving the patient (I14).

Finally, other excerpts which legitimize the relationship between accreditation and patient safety from the perspective of the nursing team were also reported.

It brought changes. Accreditation brings management and supervision. So, if there is someone who supervises, who demands those [safety] protocols, they will work (I13).

Whether you like it or not, patient safety involves everything: reception, cleaning, administrative staff. Everything involves patient safety. I think that, with accreditation being implemented, at least we have a guide, there are steps to be followed. It directs what we have to do for the patient to really have safety (I6).

Despite the clear and even specific mentioning of improvements in patient safety made possible by hospital accreditation, workers also issued content which condensed the following category. This is about patient safety for the time being seen as a dependent factor on the certification visit for accreditation, formerly seen as independent of the quality seal, constituting a duality which was labeled as questioning the theme.

PATIENT SAFETY: AN ASSET DEPENDENT ON OR INDEPENDENT OF ACCREDITATION CERTIFICATION?

Nursing workers relate that patient safety is more visible in the hospital at the specific moments which involve the assessment visit and/or accreditation certification:

(...) because many times we see so many mistakes that happen, and you’ll see when certification is approaching, people start to improve so that they [external auditors] will not catch it [notice it] (...) (I1).

In theory, everything is very beautiful. In practice, I still think it has to improve. For example, when accreditation is here: wonderful. I think there has to be a way for this to be put into practice (I4).

I think that when the accreditation staff is coming through to do [the evaluation], there is an uproar, and then, it seems to wither. I wouldn’t say that, we don’t do things, but sometimes there is so much pressure, and then like that [it goes off] (...) right? (I9).

Another nursing professional clearly lists external evaluation as a dependent factor on improvements in patient safety:

Then, the people of [name of the Accreditation Institution] come and check the workflow, if the protocols are being followed, and set goals. Regarding patient safety, they want to demand excellence in care. Of course it will never be 100%, but I believe that this verification gets everyone involved (...) (I12).

Although equally critical, the nursing staff of the accredited hospital mentions that patient safety should not depend on accreditation certification:

(...) I see that accreditation is a set of, I don’t mean to say standards, but criteria for achieving a title, a status, a certificate. And, patient safety goes far beyond accreditation (...) So, for us, patient safety is the first criterion to follow (I13).

(...) but I think that I wouldn’t need accreditation to be doing this [improvements in patient safety]. The professionals’ academic knowledge (...) could be doing all of this without the accreditation intervention (I7).

Patient safety has to be independent of anything. I think it helps, but it doesn’t change. I think if the hospital was not accredited, safety would be equal (I11).

DISCUSSION

The care safety strategies implemented at the institution arising from the accreditation process are in line with the criteria assessed by NAO, since basic quality requirements in the care provided are required for certification from the first level, focused on the principle of safety in all the activity areas(¹²). Therefore, in a way the first thematic category legitimizes that the required safety standards are recognized from the perspective of the nursing team, which is positive.

It is common to establish systematic actions for standardization in the accreditation process through implementing protocols aimed at care procedures(⁸), as mentioned in the excerpts of I6, I8 and I10, which discuss processes being directed in accordance with the safety protocols. This is important, even externally to the context of accreditation, since the adoption of good practices determined by protocols is a recommendation to attain and increase safety in care processes(¹⁷).

It is worth considering that accreditation favors safety culture in the institution, as evidenced by the mentioning of safety protocols related to processes and improvements according to fragments of the reports contained in the first axis, such as the use of bracelets and nameplates, falls prevention through the use of side rails on all beds, control of high-risk medications and control of nosocomial infection. Such actions are fundamental for improving hospital quality and safety of inpatients, and not only is their implementation essential, but also monitoring through cyclical and systematized measures of evaluation(⁴).

Other aspects related to patient safety based on accreditation certification were mentioned, including monitoring the accrediting institution as a stimulus for improvements in the hospital, as mentioned by I12, the safety barriers mentioned by I4, and the interactions between the processes which permeate the services provided at the institution and which came from the safety protocols, as mentioned by I14. This entire collection was listed as a subsidy for improvements in safe care, agreeing with the effectiveness of accreditation in improving patient care and safety(¹⁸), which possibly relates to a better developed culture of quality and safety in the accredited organization.

Therefore, it is problematized that professionals demonstrate that they have incorporated new ways of acting in relation to everyday events which interfere with patient safety. This is praiseworthy, and even a basic premise of accreditation, as its well-defined methods seek to reinforce the rationality of health work in order to subsidize strategic quality and promote a culture of improvement(⁸,¹²).

Considering that the culture in an organization is instituted in view of the values, behaviors and practices shared among the people who are inserted in the work process(¹⁹), the safety culture established in the institution is evident, since the reports in the first thematic category refer to care safety protocols and strategies arising from accreditation. However, it is prudent to interpret this data critically, as implementation of systemic and rational actions does not exclude proactive behavior (including that of managers) for continuous improvement and learning from mistakes, which are also basic premises of a positive organizational culture for care safety(²⁰).

Regarding continuous improvement, a recent study developed in Abu Dhabi through a time series analysis over eight years in different accreditation cycles demonstrated that the quality management system tends to sustain improvements in the quality of direct care; this is because the authors infer that the best performances tend to be sustained over time when submitting to the first certification visit, solidifying greater reliability to the improvement process(²¹).

Consideration is given to the effective care results in view of the safety culture related to accreditation, since there is a significant correlation between safety culture and hospital safety results(²²), as well as a consistently positive association between safety culture and related patient results to the system, such as mortality rates, failure to rescue, readmission rates and adverse events/medication errors(¹⁹).

By fostering a culture of improvement in care safety, mainly translated by the incorporation of rational patient safety actions in this study, the accredited hospital seems to meet the culture of positive safety. However, it is noteworthy that the safety culture by itself can and should be measured(²⁰,²²), which therefore shows future research path(s).

From the perspective of nursing, there was recognition of the relationship between accreditation and patient safety, as related by I13 when mentioning the direction that the certification process promotes through supervision of actions, as such “pressure” is seen as a guarantee of compliance with the protocols. Furthermore, the guidance promoted by accreditation as an effective way to guarantee patient safety was also listed by I6, which complements the assertion of safety culture by mentioning that safety permeates all areas of the institution, including support areas such as the hygiene sector, or even the administrative areas, thus constituting a fact which is consistent with the NAO’s systemic assessment principles(¹²).

The results of the study and the literature show a convergence in the sense that accreditation can contribute to strengthening institutional safety culture in care processes, with the patient as the center of care, involving all teams in a transversal way, promoting procedure standardization and helping to foster a learning culture with the failures which occur in the processes.

Although accreditation was listed as a means of favoring patient safety actions, workers mentioned aspects which generate duality in the dependency relationship between accreditation and patient safety. On the one hand (according to excerpts from I1, I4 and I9), patient safety is more evident in the previous or immediate moments of the assessment and/or certification visit when mentioning that there is mainly mobilization for the improvements to be put into practice when the evaluating institution is present.

The fact described above can be explained by the perspective of the planned accreditation monitoring, which promotes a stimulus for carrying out the actions required to achieve/maintain certification in the institution(¹²). Such monitoring is both conducted by internal audits which take place at the hospital, as well as during already planned maintenance visits for accreditation, being considered as important tools in the quality assessment(¹²,²³-²⁴).

Monitoring care quality is a strategic and rational management practice which does not depend on accreditation certification(⁴,⁹). Bearing this in mind, one returns to the fact that improvements or adherence to safety actions are more evident at the transversal moment of the certification/maintenance visit in a very critical way, as this inevitably generates inspection content to the accreditation. Thus, the inspection goes against the elementary principles of proactive improvement in the accreditation quality, even if these are guided by external evaluation and strictness in compliance with standards(¹²).

It is reinforced that denoting better/greater adherence to patient safety practices in a manner dependent on the accreditation certification/maintenance visit may be essentially premature, because this, in some way, may lead to the idea that the hospital does not show (at least as strongly) its concern with care safety outside the context of external evaluation, which is the right of users regardless of the institution’s insertion into a service certified by accreditation. On the other hand, patient safety was listed as an independent factor of accreditation certification, which is very positive.

The workers considered patient safety to be of paramount importance in care practice, which should not be linked as a product of certification, but rather independent and beyond this, as evidenced in the excerpts of I13, I7 and I11. Such an assertion may be based on the patient safety valuation from the perspective of nursing professionals, being fundamental in consolidating a culture of constructive safety(²⁵).

It is postulated that positioning patient safety as an independent product of accreditation certification is not only positive, but also ethical and very critical on the part of nursing workers. This is because it is ethically prudent to recognize that safe care goes beyond the common administrative-strategic dynamics of hospital quality management systems, such as accreditation(⁸), going further even if such systems, including as found in this study, leverage the robustness of patient safety actions.

The contradictory scenario found herein reinforces the originality and relevance of this study, namely: from the nursing team perspective, patient safety actions and also professional mobilization are expanded when nearing the accreditation assessment visit, but which soften afterwards. In contrast, the same workers at times infer that the concrete actions of patient safety are dependent on or are products of accreditation, and at times that safety is a much greater asset than the quality seal; a fact which is interpreted herein as essentially positive.

It is evident that this study does not cover all the knowledge of the relationship/interface between accreditation and patient safety. In addition, there are some study limitations: the impossibility of generalizing the results (although this is not foreseen in the study design), as well as the inclusion of a single professional category.

Despite the foregoing, it is believed that the mention of specific safety strategies arising from accreditation and also the nursing workers’ extensive criticality in positioning patient safety as “superior” to the quality seal are extremely important contributions to the quality management and patient safety areas. However, the impossibility of objectively affirming better patient safety results in the accredited hospital is a great prospect for future studies, including those with a quantitative and/or mixed approach.

CONCLUSION

It is concluded that the perspective of the nursing team on the relationship between accreditation and patient safety refers to the clear mentioning of safer care measures/strategies arising from the accreditation process, especially for instrumental and systematic content aspects embedded in the work process. They also emphasize patient safety, at times as dependent on (through the transversal moments of maintaining the quality seal), and at times as independent of accreditation, since safe care goes beyond (it is “greater than”) the certification itself. In this context, valuation of the accreditation process towards safer care was revealed, but also criticality among nursing workers.

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Publication Dates

• Publication in this collection
  07 Sept 2020
• Date of issue
  2020

History

• Received
  20 Dec 2018
• Accepted
  05 Nov 2019