Implications of hospital accreditation on the everyday lives of healthcare professionals

Abstracts

A fim de alcançar os mais elevados padrões assistenciais, são adotadas iniciativas voltadas para o processo de Acreditação Hospitalar, as quais impõem mudanças comportamentais, mobilização dos profissionais em busca de metas e objetivos propostos, além da melhoria permanente e contínua do atendimento prestado. Trata-se de um estudo de caso de natureza qualitativa que teve como objetivo analisar as implicações do processo de Acreditação Hospitalar no cotidiano de profissionais de saúde de um hospital privado em Belo Horizonte. Os sujeitos da pesquisa foram 34 profissionais de saúde, alocados em diferentes setores do hospital. Os dados foram coletados por meio de entrevistas semi-estruturadas e analisados por meio da técnica de análise de conteúdo. Observou-se que o processo de Acreditação se configura como uma possibilidade de crescimento e de desenvolvimento da capacidade crítica dos atores envolvidos. Contudo, as exigências impostas por este processo desencadeiam stress profissional e sobrecarga de trabalho.

Hospitais; Acreditação; Pessoal de saúde; Qualidade da assistência à saúde; Equipe de enfermagem

ARTIGO ORIGINAL

Implications of hospital accreditation on the everyday lives of healthcare professionals^*

Implicancias del proceso de Credibilidad Hospitalaria en el cotidiano de profesionales de salud

Bruna Figueiredo Manzo^I; Maria José Menezes Brito^II; Allana dos Reis Corrêa^III

^IRegistered Nurse. MSc in Nursing. Assistant Professor of the Nursing Course of the Pontifícia Universidade Católica of Minas Gerais. Member of the Research in Nursing Administration Center of the Federal University of Minas Gerais School of Nursing. Belo Horizonte, MG, Brazil. brunaamâ[e-mail]

^IIRegistered Nurse. PhD in Nursing. Adjunct Professor of the Department of Applied Nursing of the Federal University of Minas Gerais School of Nursing. Belo Horizonte, MG, Brazil. [e-mail]

^IIIRegistered Nurse. MSc in Nursing. Assistant Professor of the Department of Basic Nursing of the Federal University of Minas Gerais School of Nursing. Belo Horizonte, MG, Brazil. [e-mail]

Correspondence addressed

ABSTRACT

Hospital accreditation processes should be adopted to achieve the highest standards of healthcare. This process requires behavioral changes and mobilization of professionals in efforts to achieve goals and objectives, in addition to continuous improvement of healthcare. This qualitative case study was performed with the objective of analyzing the implications of hospital accreditation on the everyday lives of healthcare workers in a private hospital in Belo Horizonte. Subjects were 34 healthcare professionals from different sectors of the hospital. Data were collected through semi-structured interviews and subjected to content analysis. It was observed that the accreditation process was designed as an opportunity for developing and improving the critical thinking capacity of the subjects involved. However, the requirements imposed by this process may trigger occupational stress and cause work overload.

Descriptors: Hospitals; Accreditation; Health personnel; Quality of health care; Nursing, team

RESUMEN

Apuntando a alcanzar los más elevados patrones de atención, se adoptan iniciativas orientadas al proceso de Credibilidad Hospitalaria, las cuales imponen cambios comportamentales, movilización de los profesionales tras las metas y objetivos propuestos, además de la mejora constante y continua en la atención brindada. Estudio de caso cualitativo, que objetivó analizar las implicancias del proceso de Credibilidad Hospitalaria en el cotidiano de profesionales de salud de un hospital privado en Belo Horizonte. Los sujetos de la investigación fueron 34 profesionales de salud, ubicados en diferentes sectores del hospital. Los datos se recogieron mediante entrevistas semiestructuradas y fueron analizados a través del análisis de contenido. Se observó que el proceso de Credibilidad se configura como una posibilidad de crecimiento y desarrollo de la capacidad crítica de los actores involucrados. Así y todo, las exigencias impuestas por este proceso, desencadenan estrés profesional y sobrecarga laboral.

Descriptores: Hospitales; Acreditación; Personal de salud; Calidad de la atención de salud; Grupo de enfermería

INTRODUCTION

Contemporary society is transforming in a rapid and profound way. Seeking to adapt to the changes experienced by the contemporary society and, simultaneously, to meet the requirements of an increasingly demanding clientele, managers of the healthcare services have adopted new attitudes that require an increase in the level of quality. In this perspective, we have the current Brazilian scenario in the context of a globalized economy where the institutions no longer support the costs related to poor quality, i.e. high costs with increasing morbidity and mortality, expenses for reworking and expenditure with inefficient process; furthermore, attention is drawn to the compromise of the image of the organization for the society, as well as the loss of clients and the market⁽¹⁾.

Considering the need for the development of a strategy to enhance the quality of the healthcare services, the Hospital Accreditation Program is an evaluation procedure of institutional resources in a periodic, voluntary, rationalized, and ordered way with the continuing education of professionals, in order to guarantee the quality of care through previously accepted standards⁽²⁾. The Accreditation should therefore be understood as two dimensions. The first, as an educational process, which leads the institutions providing healthcare services, especially the healthcare professionals, to acquire the culture of quality for the implementation of the management of excellence, fundamental to the process. The second dimension refers to the process of evaluation and the quality certification of the services, analyzing and certifying the degree of performance achieved by the institution according to predefined patterns⁽³⁾.

This movement towards quality reflects the need for fundamental changes in the organizations, as the valorization of individuals and the attention to social relationships become essential in order to acquire the title of excellence. In this scenario, the healthcare professionals emerge as the core of the quality policy, having an essential role in ensuring and maintaining the process. Through the commitment to the quality policy established by the institution, the professionals engage and strengthen the culture of client centered improvement and the determination to perform services that meet the requirements of the National Accreditation Organization (NAO), safely and with excellence. The great differences in the organizations are in the area of the quality of personal and in the professional performance of their human resources. The technology and structure of the organizations can have little meaning if the people do not feel committed to quality, especially with regard to meeting the needs of the clients⁽⁴⁾.

The study of quality involves, as well as a set of techniques, a wider dimension of actions of the social process, where the main elements for its development are those that act and perform a role in this process⁽⁵⁾. Every effort to improve an organization should begin by focusing the professionals regarding education, skills development, responsibility awareness formation, teamwork training and development of the work ethic concept⁽⁴⁾. It can be seen, therefore, that the implementation of the quality system is no simple task, and, in contrast, presents a major challenge to be faced by managers and professionals seeking to adapt their work processes to excellence in the care.

It is hoped that this study may assist healthcare teams to reflect on the quality process, the social responsibility, and the changes in habits and concepts embedded in the process of Hospital Accreditation. Once the implications of the quality system are recognized by the professionals, the maintenance of the entire process and the achievement of excellence in the care will become easier. The aim of this study is to analyze the implications of the Accreditation process in the quotidian of the healthcare professionals.

THEORETICAL FRAMEWORK

The concern with quality, present in healthcare since Hippocrates, became more intense in the twentieth century. Important considerations were made by a researcher⁽⁶⁾, in 1998, regarding the different quality models that explain the particularities of the transposition of quality for the area of healthcare. In this context, the author highlights the systematic analysis of six key attributes. The first relates to the efficacy as an ability to achieve the best results in the care through better actions. The second attribute is related to the idea of efficiency, which consists of reducing the cost of care without reducing the improvements achieved. The third refers to the balance between the costs and the effects of the actions on the care. The fourth focuses on the acceptability of the service regarding the expectations of the patients and family members. The fifth attribute proposes compliance with the social concepts expressed in ethical principles, values, standards, regulations and laws. Finally, the author refers to equity in healthcare as the last attribute. Therefore, among the strategies for the assurance and improvement of the quality is the influence of the professional performance and of the upgrading of the management model⁽⁶⁾.

Since their inception, the hospitals have undergone various changes, mainly aimed at improving the quality of the care. Major technological advances have occurred and in parallel to these, new forms of reorganization and restructuring became necessary in these institutions⁽¹⁾. Some authors emphasize that the present moment is permeated by huge transformations among which the globalization of the economy, the rising costs of the services, the increase in technology and advances in science, the advances in information technology, and the production and dissemination of technical knowledge can be highlighted⁽⁷⁾.

The hospital institutions have become more complex, having a greater need to seek innovations in products and services to maintain themselves in an increasingly competitive market. Therefore, the changes were inevitable and necessary for the survival of these institutions⁽⁸⁾. The creation of instruments aimed at improving the quality of healthcare has become a universal phenomenon, changing from a theoretical concept to a reality with the essence of guaranteeing the survival of the businesses and of the goods production and service sectors. Furthermore, the evaluation constitutes a fundamental pillar of the healthcare guarantee and is understood as being an instrument of the management of healthcare services necessary to measure the efforts of the organization, the quality of the services provided, as well as their usefulness and social relevance. In this context, Hospital Accreditation is presented as one of the methods of evaluation of the resources of the healthcare, voluntary, periodic and reserve organizations, which tends to ensure the quality of the care through pre-established standards⁽⁹⁾.

Hospital Accreditation is configured as a methodology developed for improving the quality of the care provided in all the services of a hospital. It is based on the evaluation of the desirable standards of reference, constructed by experts in the area and previously divulged, and on the indicators or instruments that the evaluator employs to verify the standards that are being analyzed. The request for Accreditation by the institution is a voluntary, periodic, spontaneous, reserved and private action, where it is intended to obtain the Accreditation status according to previously accepted standards, in which the accrediting institution that will develop the Accreditation process is chosen⁽¹⁰⁾.

In recent years, important changes have been perceived in the healthcare area with regard to the need to achieve greater competitiveness and to conquer new markets. The growing increases in the costs of the care offered, the need to meet client expectations and rights, and the concern with the guarantee of the safety of the care are aspects that require a change from the healthcare professionals in the way healthcare is managed, being innovators and, above all, showing excellence in their work. To ensure this excellence and to monitor the advances, the hospitals have the need to develop evaluation methods for the provision of their services⁽¹¹⁾.

The Brazilian Program of Hospital Accreditation aims for broad knowledge regarding a continuous process of care quality improvement, through the periodic evaluation of the service. For this, in the hospital context, mechanisms for evaluation and continuous improvement of the quality of care provided are introduced. Its solidification occurs through the development of the Brazilian Manual of Hospital Accreditation (MBAH), which discusses the benefits that the healthcare organizations obtain when they enter the Hospital Accreditation process, since the institution will demonstrate responsibility and commitment to safety, to professional ethics, to the procedures performed and to the guarantee of the quality of the care to the population^(8,12).

The Brazilian Hospital Accreditation Manual is an institutional quality evaluation instrument, which is composed of sections and subsections. The sections represent the services, sectors or units with similar characteristics so that the institution is evaluated following a systemic consistency; the subsections deal with the scope of each service, sector or unit, according to three levels, from the most simple to the most complex, always with a process of incorporating the preceding requirements of lower complexity⁽⁸⁾. The logic of the subsections is that all have the same degree of importance within the evaluation process. Each subsection consists of standards that seek to evaluate structure, process and outcome within a single service, sector or unit, with each standard consisting of a definition and a list of guidance items that assist in identifying what it seeks to evaluate and in the preparation for the Accreditation process of the healthcare service provision institutions. A higher level is reached only when the former has been achieved⁽⁹⁾.

The standards required and verified in the evaluation are divided into levels 1, 2 and 3, according to their guiding principles and standards, with each standard representing a definition and a checklist that allows the identification of its needs and the compliance with the standard established:

Level 1: Covers the formal, technical and structural requirements for its activity according to the corresponding legislation; identifies specific risks and their management with the focus on safety. Principle: Safety.

Level 2: Manages the processes and their systemic interactions, provides systematization of the measurement and evaluation of the processes; has a continuing education and training program, and is focused on the improvement of processes. Principle: Organization (Processes).

Level 3: Uses organizational measuring perspectives, aligned to the strategies and correlated to the performance indicators of the processes; provides systematic comparisons with relevant external reference, as well as evidence of favorable trends for the indicators; presents implemented innovations and improvements, arising from the critical-analysis process. Principle: Excellence in the Management (Results)⁽⁸⁾.

METHOD

This is a case study with a qualitative approach. Qualitative studies are applicable to the study of history, of relationships, of ideas, of beliefs, of perceptions and of opinions, products of the interpretations that social subjects make regarding how they live, construct their artifacts, feel and think⁽¹³⁾. Regarding the case study, it presents itself as an appropriate strategy when it comes to issues in which there are contemporary phenomena embedded in real-life contexts and can be complemented by other exploratory and descriptive investigations. The case study is used as a research strategy in organizational and management studies, contributing, in a unique way, to the comprehension of complex phenomena, at individual, organizational, social and political levels, allowing the preservation of the significant characteristics of real-life events⁽¹⁴⁾.

The study scenario was a mid-sized private hospital, located in Belo Horizonte and opened in 2004 with the perspective of being a reference for quality in the care for all the hospitals in the private system. The study includes the In-patient, Surgical Block (SB) and Progressive Care Unit (PCU) sectors. The inclusion criteria for the sectors mentioned was the fact that they have been in existence since the time of inauguration up to the first external audit, allowing the workers a unique experience in relation to the Accreditation process.

The choice of study subjects was intentional and restricted to the professionals who had participated in the Hospital Accreditation process since the first audit and who provided direct and continuous care to the users of the service. A total of 34 professionals were included, consisting of nine registered nurses, 15 nursing technicians, six physicians, one phonoaudiologist and three physiotherapists, with the majority (88.2%) being female. Concerning the length of employment in the institution, 64.7% of the interviewees had 3 to 4 years and 67.6% were professionals working in the PCU. Workers were excluded with less than three years in the institution due to the fact they had not experienced the Accreditation process since the first audit.

Prior to the data collection phase the project was authorized by the hospital and approved by the research ethics committee of UFMG, with the Protocol of approval ETIC No. 2567/08. The subjects were informed about the aim, rationale and purposes of the study, according to Resolution No. 196/96 of the National Health Council⁽¹⁵⁾, which deals with ethical aspects of research involving human beings. All subjects who agreed to participate in the study signed the Terms of Free Prior Informed Consent. The interviews were performed using a semi-structured script, between the months of September and November 2008.

The interviews were conducted until the saturation of information was reached, which can be defined as the suspension of the inclusion of new participants when the data obtained begins to present, from the evaluation of the researcher, some redundancy or repetition, with it not being considered relevant to persist in the data collection⁽¹⁶⁾. To maintain the anonymity of the professionals, the interviews were identified by the initials of each profession and by a number referring to each professional category, with E1 to E9 for the nurses, T1 to T15 for the nursing technicians, M1 to M6 for the physicians, F1 for the phonoaudiologist and FT1 to FT3 for the physiotherapists. The data were subjected to Technical Content Analysis, which seeks to achieve a deeper interpretation of the phenomenon beyond the scope of merely describing the manifest content of the message⁽¹⁷⁾. This technique unfolds in three distinct phases: pre-analysis, exploration of the material and treatment of the results which allows the classification and aggregation of the findings according to the explicit problem⁽¹³⁾. For this phase, the text was cut into registry units and the thematic categories established, namely: the nebulous face of the Accreditation and the Accreditation as a possibility for growth and job satisfaction.

RESULTS

Implications of the Accreditation process for the healthcare professionals

The statements of the interviewed professionals permitted the distinct aspects of the Hospital Accreditation process and its influence in the work quotidian of these professionals to be highlighted. It was observed, therefore, that the Hospital Accreditation is influenced by the level of motivation and involvement of the employees and, at the same time, significantly influences the work context of the healthcare professionals. From this perspective, positive and negative aspects of this process were identified, resulting in the following thematic categories: The nebulous face of the Accreditation and Accreditation as a possibility for growth and job satisfaction.

The nebulous face of the Accreditation

With regards to the employees of the hospital studied, distinct and often ambiguous perceptions were observed in relation to the Accreditation process in their work quotidian. Therefore, on one hand positive aspects were highlighted, often relate to the possibility of personal growth and of valorization of the curriculum, achieved by conducting training and refresher courses. While conversely, negative aspects resulting from stress and from the pressure arising from the demands imposed by the certification processes were also demonstrated, which create the feeling of demotivation, as shown by the following statement:

In a certain way, the employee grows, because he stops being involved only with the medical prescription and following the prescription and he begins to create a kind of critical thinking. However, at the same time, I see that he has to divide himself, to spread himself around. Therefore, he has to stay a while dedicating himself to the NAO, to the paperwork, and to all the bureaucratization of care here, and it is dispensed with. It is very heavy, and in this the patient loses, and the employee leaves here stressed, because he always has the feeling I did not manage to do everything. So I think this demotivates the worker over the long-term (E3).

...the negative of the Accreditation is the stress (T5).

In relation to the position of the interviewees regarding the negative aspects, some authors state that the changes in the organizations require the workers to alter their structure of beliefs and personal values, causing them to experience situations of loss of reference, fear and distress with psychological responses to the threatening situations⁽⁵⁾. Also from this perspective, the Accreditation process was referred to as a situation of constant pressure and one that triggers stress for the professionals involved without offering them anything in return despite being beneficial to the client, as evidenced by the following statement:

Professionally I think there is a lot of pressure for us in relation to everything. It is directed toward the quality of the external client and forgetting the quality of the internal client (M4).

The lack of valorization was also a frequent complaint of the study subjects. There was a feeling of low prestige before the great challenge that occurs in the day-to-day, since errors are noticed and criticized, while praise in the face of the goals and victories does not present major repercussions, as shown below:

I think that professionals feel stressed with so much pressure, all the time they are watched for mistakes, sometimes they do not receive much praise for something they did well. They are always looking for the mistakes (E9).

It is noted that the healthcare professionals position themselves in relation to a scenario permeated by overload and pressure, it should be noted that such a situation, although inherent in any system that uses continuous evaluation, can be softened by the increase of strategies that seek the valorization of the subjects involved, in order to provide continuity and greater adherence to the management of quality. Also worth highlighting is the fact that some workers associated the proposed acquisition of the title with the increase in remuneration. This association was found to be related to the need for the engagement of the workers with the aims of the hospital, with the increase in the demands and in the stress, and with the improvement of the care resulting from better training, as observed in the following statement:

For us professionals it does not make any difference, nothing has changed. Because you gain the title and do not get a salary increase. It does not improve. With or without NAO nothing changes. I think it is worse to have NAO: the pressure is very high (FT1).

In a process of quality improvement, a system of rewards and recognition of the efforts of people who contribute to the service excellence should be considered. These efforts stimulate and motivate people when properly rewarded, renewing the commitment to the quality and excellence of the services provided⁽⁴⁾.

Accreditation as a possibility for growth and job satisfaction

With regard to the positive perception, it was observed that the Accreditation triggers feelings of pride, satisfaction and recognition in the professional. These feelings are related to the sharing of the responsibility for gaining the title and for the valorization of the hospital. The pride comes from the sense of 'belonging' to a company that is admired and from identification of their personal values with the values of the organization⁽⁵⁾. The following statements explain this idea:

I think we feel very satisfied when we pass the audit, you see that the hospital was accredited and that we were involved, and that out there this will make a difference for us (T15).

You work at hospital X that is accredited, how cool, I heard that it is very good there, so you become proud (M1).

Some characteristics, according to the authors, are sources of pride for the employees, namely: the variety of tasks that require a variety of skills; the identity of the work that allows the performance of something perceived as significant, tangible and identifiable; and the meaning of the work, which is its ability to have a positive impact on the well-being of other people⁽¹⁸⁾. Illustrating the point of view of the authors, the professionals interviewed spoke about the safety provided by the Accreditation process, since the employee working in an accredited service feels better prepared to meet the needs of the clients as they can provide material, human and technical resources of greater complexity while maintaining the level of quality by standardizing routines and greater organization, which can be evidenced in this excerpt:

For the professionals, I think that from the moment that certain things are standardized, this ends up being beneficial to the employee because it is an environment that is better for working and safer than in new institutions that do not have it (E4).

The Accreditation process promotes the increase of the improvement of the working conditions through the safety acquired, as well as providing the stability of the organizational climate among the healthcare professionals, while simultaneously establishing a more pleasant working environment conducive to strengthening the human relationships. The improvement in the working conditions favors the relationship of growth, enthusiasm and pleasure of the employees, generating motivation to seek future experiences and to develop the work efficiently, with quality, in an environment of satisfaction and happiness. Thus, the Accreditation program contributes to the improvement of the organizational climate, encouraging companionship among the employees of the service, since they work in an accredited hospital, and participation in the activities related to the evaluation creates motivation in the people. The following statement addresses this idea:

The hospital will be looking for a cool climate for that professional, so that among the internal clientele there is a climate, a cool relationship, also concerning the satisfaction of the employees with the work conditions (T3).

It was noticed that, when acting in a scenario of transformation in the hospital context, professionals from different categories (re)signify their quotidian actions, including what they do and how they relate to each other. Organizational studies have shown that motivation and job satisfaction, beyond the remuneration or benefits received, is accomplished through a set of objective and subjective factors. Among the subjective factors the meaning assigned to the work for those who perform it is highlighted. To be meaningful, the work must include, in its performance, the practice and development of skills, the exercise of judgments and free decisions, information about its performance and the opportunity to adjust it⁽⁴⁾. In the context of Accreditation, quality is everything that adds value to the work or to the relationships and is directly linked to the productivity of the institution, involving human relationships and personal and professional development⁽⁵⁾.

DISCUSSION

The results described in this study indicate positive and negative aspects of the Hospital Accreditation process that directly influence the work quotidian of these professionals. The professionals do not uniformly visualize the influence of the Accreditation process, some employees could understand the process in a positive way, while others only approached it with a negative view. However, there were those who could reflect on the Accreditation, extracting the negative aspects and the success points of the process.

For the professionals who viewed the process positively, the Accreditation brings pride and satisfaction, due to the feeling of responsibility for gaining the title and for the valorization of the hospital. Other positive aspects mentioned are often related to the possibility of personal growth and the enhancement of the curriculum with the learning. The issue of safety provided for the healthcare professional by the Accreditation process was also revealed. The study subjects mentioned that the employee working in an accredited service feels better prepared to meet the requests of the clients, while maintaining the level of quality through the standardization of routines and greater organization.

Among the negative points, it was noted that the healthcare professionals find themselves in a setting permeated by overload, pressure, stress, lack of valorization and recognition. It should be noted that such a situation, although inherent in any system that uses continuous evaluation and seeks continuous improvement, can be softened by an increase in strategies that seek the valorization of the subjects involved, in order to provide continuity and greater adherence to the management of quality.

In the comparison between the positive reasons and the negative arguments presented by the interviewees in the context of the implications of the Accreditation process for the professional environment, it was observed that the valorization and the knowledge acquired by each individual overcome the stress and pressure, since it is impossible to achieve improvements without an increase in the responsibility. Indeed, perhaps the negative points presented arise from the novelty itself, as the new creates immediate yet momentary insecurity and resistance. Therefore, it is undeniable that rewards, focused on the valorization and the recognition of the professional, through praise, words of support and other incentives mainly of a financial nature, would minimize the negative view presented by the interviewees.

The constant need for investment in continuing education is emphasized for the realization of the changes in the internal and external processes of the organization and to respond to the demands resulting simultaneously from the certification protocols and from the healthcare professionals. Thus, the Accreditation may represent an important strategy for staff training in the hospital context, which reflects the current trend of people management, in which the reconciliation of the organizational expectations and those of the workers should be promoted.

CONCLUSION

The incessant search for the improvement of the quality of the services provided is the route for the institutions that struggle to remain in the competitive market and that prize care excellence. Therefore, hospitals are searching for new care models and other forms of management, aiming to achieve results that optimize resources, increase the humanized care, and guarantee the improvement of the service offered. In this context, the Hospital Accreditation program appears as a possibility to promote changes in the current scenario eroded by the technicist model of care. The new quality process brings changes in habits, values and behavior, imposes the disruption of mechanical care on the subjects involved, and fosters an organizational environment of excellence.

This study sought to deepen the reflection related to the implications of the Accreditation process for the healthcare professionals, reinforcing the fact that, for the implementation, adherence and maintenance of the quality process in the hospitals it is essential, above all, to know the perception of those subjects regarding the Accreditation. It is expected, therefore, that from the greater knowledge about the implications of the Accreditation process in the quotidian of the healthcare professionals, barriers will be removed, behavior changed and the action qualified. In addition, it is hoped that this study will inspire further research on the theme and provoke motivation and commitment in the healthcare professionals to promote the necessary changes, as well as to provide the patient with a better provision of services, with humanized care excellence.

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Correspondência:

Bruna Figueiredo Manzo

Rua Professor Baroni, 235/601 - Gutierrez

CEP 30440-140 - Belo Horizonte, MG, Brasil

*

Extraído da dissertação "O processo de Acreditação Hospitalar na perspectiva de profissionais de saúde", Escola de Enfermagem da Universidade Federal de Minas Gerais, 2009.

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Apr 2012

History

• Received
  12 Feb 2010
• Accepted
  11 July 2011