The history of quality and safety of the surgical patient: from the initial standards to the present day

There are currently various concepts related to quality, which have already been deeply implemented by many hospitals and other healthcare institutions. The search for continuous improvement, implementation of a quality culture and hospital accreditation has also been common, in such institutions. However, the history of hospital audits and accreditation is complex and full of dynamic concepts. The American College of Surgeons was pioneer in publishing, more than a century ago, the first document pertaining quality standards. After that, various programs and concepts have been developed and remodeled by distinct entities. In this article, we briefly review the history of quality in the world and Brazil, besides discussing related concepts regarding its assessment in healthcare.

have been modernized with the evolution of the industry, and are responsible for several quality implementation programs today, not only in the production area but also in other industry sectors. Years later, in the middle of the 20th century, quality was further tackled by the Asian Tigers as part of the international industrial scenario 4 .
In the meantime, the healthcare business has also taken part in the quality movement with programs that have led to the development of the accreditation concept.
Accreditation consists of an evaluation method that aims at gradually increasing the quality of a healthcare institution and the provided assistance 5 . It is the recognition by external and independent peers 6 for the excellency in standardized criteria 7 . The aim of accreditation programs is continuing education and not inspection 8 or punishment 9 . There are programs in more than 90 countries 10 , each adapted to the reality for which it operates 7 .

THE HEALTHCARE ACCREDITATION CONCEPT
O The concept of accreditation has evolved with the history of hospital assessments, which started with the minimum standards of the "American College of Surgeons" (ACS) 11  Hospitals that seek to obtain certificates provided by accreditation bodies show commitment to safety, efficiency and responsibility 13 . Accreditation programs encourage the implementation of ideal healthcare management practices 14 , which are related to the improvement of the service and its quality, resulting in greater satisfaction 15  Before any accreditation program was created, the idea of systematizing medical quality had previously been presented by an American surgeon -Ernest A. The "Standard of Efficiency", is a document published in 1918, by the ACS, which is the prototype of hospital accreditation programs 11 ( Figure 1). Since then, the number of programs has increased exponentially 6 . This document was the basis for a field study, carried out in 1919, which evaluated 692 American hospitals with more than 100 beds. Alarming results were identified, as only 13% of hospitals reached the standards described in the document 11 . Such numbers caused an uproar in the medical community, raising problems to large American hospitals and leading to changes in the attitudes of institutions that had initially failed. Such initiative led to the restructuring of the entire assistance system, which is still seen up to now 11 .
The "Standard of Efficiency" is the cornerstone of hospital accreditation and takes into account basic aspects that are still a reality in hospitals today: proper organization of the medical staff; correct filling of medical records and; availability of diagnostic and therapeutic It is important to highlight that certification should not be the objective of the hospital that decides to undergo the accreditation process, but rather, the implementation of a quality culture 18 .

THE HISTORY OF HEALTHCARE QUALITY
The idea of quality in healthcare permeates treaties of ancient civilizations. It was initially mentioned in the code of Hammurabi, in Babylon, and in the writings of Hippocrates 19 . Although not a new topic, the initial efforts were fragmented and not correlated 20 .
From the 1980s onwards, accreditation programs began to be adopted outside the United States, initially covering other English-speaking countries and later, Latin America and Asian countries 24 .
In 1987, the JCAH once again changed its name to the "Joint Commission on Accreditation of Healthcare Organization" (JCAHO) 25  This had 333 items divided into three areas (physical plant, equipment and organization) 23 . For a long time, the ReClar was the "accreditation" document used in Brazil 28 . Subsequently, in the 1970s, the Ministry of Health published a series of ordinances in order to improve quality in the healthcare system 28 .
In 1987, the Pan American Health Organization (PAHO), through the Technical Institute for the Accreditation of Health Establishments, tackles the creation of the "Accreditation Manual" 12 . This document, which has a series of necessary conditions for a hospital to be accredited, resources 23 . In 1924, the ACS published the hospital standardization program, a document that defended the same principles, and it the precursor of the concepts of quality and safety 24 .
In 1950, with the increase demand for hospital evaluations (in that year, 3290 institutions had been approved) and the need to verify non-surgical structures, the ACS started to require the support from other national professional entities to develop the assessment activities.
The "American College of Physicians", the "American In 1966, the "Hospital Accreditation Program" was revised and started to demand not only the minimum requirements for the offered services, but also to request the optimal requirements for healthcare treatments. This decision was driven by the fact that many hospitals had already met the minimum requirements and were no longer challenged to improve services. Another important factor, for this review, was the fact that the American government started to require minimum quality of care in the "Medicare" system, forcing the JCAH to tackle a movement which stimulated the improvement above that

THE FUTURE OF HEALTH QUALITY
The history of accreditation in Brazil is still in development, the cornerstones were imported from international models. However, since the 90s of the last century, national needs have been addressed by the development of new manuals, in order to contemplate Brazilian requirements. Around the world, the idea of implementing the quality culture has reached other levels of care, such as primary care 15 . Considering that in Brazil, the gateway to the Unified Health System (SUS) is the primary care health unit (UBS), this movement has also evolved towards accreditation of this scenario.
The questioning regarding the real role of certifications to the improvement of the quality for patient care and treatment is recurrent in the literature. This is due to the absence of an ideal parameter to measure such data. Observational studies 10,26 , systematic reviews 6 and prospective studies 14 have been carried out to try to assess this role, and the results are conflicting. However, even with the lack of consensus, there is a certainty: the evaluation processes and certifications promote the habit of quality in the hospital environment 30 . In other words, they establish attitudes and processes that reduce errors and standardize decision-making, thus decreasing room for failures 31 . Morbidity and mortality costs, in addition to those related to the poor healthcare quality are not acceptable, under the current health management scenario 25,30 . Hospital certifications will not be replaced anytime soon, but they should offer new insights on quality of care so that the differences between accredited and nonaccredited institutions are more measurable 25,30 .
Finally, it is necessary to allude to the new chapter on healthcare quality that is currently being written, the formulation and application of certifications in the area of primary healthcare (PHC), reaching the UBSs, in Brazil. This is a trend that has been seen elsewhere in the world 15,32 .
In Brazil, the advance of theoretical

Acknowledgment
We thank the Department of Surgery at the Federal University of Paraná -UFPR for introducing the topic in our studies and supporting us in the publication.
formulations on the evaluation of these units in the last 17 years, and considering the country is one of the biggest systemic experiences in PHC is certainly paramount. The idea of certification and evaluation processes has further impacted the system evolution.
In 2011, with the program for improving access and quality (PMAQ), it was necessary to establish an external evaluation institution, which was carried out by 40 universities and the federal research centers.
With these efforts, the researchers concluded that in this healthcare scenario and under the constitutional context of the SUS, quality is the breadth of the actions officially planned for each healthcare condition 33