Quality of nursing documentation before and after the Hospital Accreditation in a university hospital

ABSTRACT Objective: to analyze the quality of nursing documentation by comparing the periods before and after the preparation for the hospital accreditation, using the Quality of Nursing Diagnoses, Interventions and Outcomes - Brazilian version (Q-DIO- Brazilian version). Method: observational study of interventions conducted in a university hospital. Nursing documentation of 112 medical records for the period before and 112 for the period after the hospital accreditation were compared using the Q-DIO instrument - Brazilian version. Data were statistically analyzed. Results: there was a significant improvement in the quality of nursing documentation. When the total score of the instrument was evaluated, a significant improvement was observed in 24 out of the 29 items (82.8%). Conclusion: there was commitment to the shift of culture by means of the interventions carried out, which resulted in the conquest of the quality seal ensured by the Joint Commission International.


Introduction
The major purpose of the hospital accreditation is to create a culture of safety and quality in the institutions interested in continually improving patient care processes (1) . In this context, it is worth pointing out that electronic health records are relevant information sources to monitor the achieved quality and safety levels (2) . This operationalization is in line with the principles of the institution where the study was carried out. In this scenario, the nurses have used the information technology as a tool for promoting quality in health care management, especially for clinical decision making in the Nursing Process (NP) (1) .
In order to adhere to the international accreditation, various strategies aiming to obtain the quality seal were employed in the hospital, resulting in the recognition in 2013. To achieve this goal, it was sought an organization based on the criteria described in the Accreditation

Standards Manual of the Joint Commission International
(JCI) for hospitals (3) .
From the creation of this manual, the records become an important focus of evaluation in institutions, both at organizational and assistance levels.
Consequently, the quality of computerized nursing documentation assumes a position of great importance for achieving the hospital accreditation. This manual is divided into two sections: Section I -Patient-Centered Care Standards, composed of eight evaluative items and Section II -Health Facilities Management Standards, composed of six evaluative items (1) . Ten out of the fourteen items evaluated by the JCI are directly related to the nursing documentation, that is, all items of section I and two of section II include in their assessment, the documentation performed by the nursing team in the patient medical record.
In this evaluation context, the nursing team should carry out records that reflect the patient care in a clear and reliable fashion, considering a new professional approach in response to technological advances, globalization and the change required in the workplace (4) . In this way, only having a computerized system does not ensure the completeness and quality of records (5) , requiring assessments and improvements in a systematic way.
Within this perspective is the instrument Quality of Nursing Diagnoses, Interventions and Outcomes -Brazilian version (Q-DIO-Brazilian version) validated for the Portuguese language to assess the quality of nursing documentation (6)(7) . This has been used as an indicator to assess and compare the quality of these records and used as a tool in auditing systems and in the assessment of the impact of the implemented educational programs (7) .
In order to assess the changes in quality of computerized nursing documentation, this study evaluated this quality at two different moments, before and after the preparation for the hospital accreditation by means of the Q-DIO -Brazilian version.
As justification of the study, it is believed that this will encourage hospitals to establish goals and improvements in care, aiming at the quality of nursing documentation, through interventions to increase the commitment of the institution in favour of quality and safety of health care provided.
In this sense, it was intended to answer the following research question: Did the intervention developed during the hospital accreditation process help to improve the quality of nursing documentation?

Objetive
To analyze the quality of nursing documentation by comparing the periods before and after the preparation for the hospital accreditation and using the Q-DIO -Brazilian version.

Method
This is an observational study of interventions, which can be used when there is no consensus about the efficiency of a single activity implemented;

Results
The total score of the instrument Q-DIO -Brazilian version showed a significant difference between the years, considering a minimum score of "zero" and a  Table 1.
Rev. Latino-Am. Enfermagem 2016;24:e2813 and increasing the proportions of the other categories, as shown in Table 2. Nomura ATG, Barragan MS, Almeida MA.
By evaluating the differences in each assignment category of questions between the years, it was observed that there were no statistical differences in the Questions 3, 8 and 9 of the category 1, although there were more than 10% increase between the years.
As for the domain Nursing diagnoses as product, con-sidering the differences in the records assessment categories between the years, no statistical difference was observed in category 1 on nearly all questions, except in Question 18. It is observed a small amount of records in the category "zero", in contrast to a large amount in the category 2 in the assessed years, as shown in Table 3.   Table 5.

Discussion
Hospital Accreditation encouraged the planning and implementation of interventions capable of resulting in the improvement of nursing documentation. In a crosssectional study, it was found that nurses from hospitals accredited to the accreditation were more receptive to changes and improvements when compared to the nonaccredited hospitals. In this perspective, this assessment process motivates professionals to organize themselves to better understand the compreensive patient care (9) .
Considering the total score and the four domains of the prescriptions was completely checked (13) .
Among the items of the domain Nursing Outcomes, the Question 23 showed no significant improvement in quality between the years evaluated. However, when the classification category was assessed between the years, it was noticed a significant improvement in category 2, "Full documentation", increasing from 67% to 80.4%.

As for the significant improvement in quality of
Question 24 between the years, it was shown that nursing diagnoses have been better registered and/ or reformulated in the final year of the educational a significant overall improvement of records between the years evaluated. Among the domains of Q-DIO -Brazilian version, which showed the most representative improvement was the Nursing Diagnosis as Process.

Its questions involve individual and overall assessment
to identify relevant nursing information in the records during the first 24 hours of the patient hospitalization (7) .
This information is usually found in the document Nursing Anamnesis, in which it is possible to know the customer, establish links, identify the biopsychosocial and spiritual changes, and thus define the nursing diagnoses, expected outcomes and interventions that enable the patient improvement (10) .
As rescuing a holistic view on this patient (10) .
The inadequacy of Question 7 may have been a result of the unpreparedness of the nurses to assess gender and sexuality issues. It is highlighted the lack of studies on sexuality in the training of nurses, despite its importance in overcoming the heteronormativity and considering the new marital patterns and family arrangements (11) .
As regards the Nursing Evolution, the domain Nursing diagnosis as product assesses the nursing documentation regarding the individual situation of the patient according to the format Problem, Etiology, Signs and Symptoms (PES), nursing diagnoses and goals (6) .
The evolution model adopted in the institution contains the items: subjective, objective, interpretation and practices, including those related to patient education.
Since the system used is computerized and uses the terminology of the NANDA-I (8) (13)(14) . Although the institution where the study was conducted has not included the Nursing Outcomes Classification (NOC) in the NP (15) up to this moment, Question 25 also showed a significant improvement. This is due to the more frequent use of the terms "improved", "worsened", "maintained" and documentation but also in the nursing practices (8)(9)(10)(11)(12)(13)(14)(15)(16) . Based on these results, it is clear that the operationalization of NOC in the institution tends to benefit the quality of nursing documentation, facilitated by the articulation of standardized languages and computerised systems (15) .
Educational strategies for training of nurses will be essential for the implementation of this stage. It is observed, therefore, a strong influence of NP in the Hospital Accreditation process, as the record is an important evidence of the quality of care provided to patients and relatives. Therefore, it is necessary to reorganize the work processes through continuous training of the nursing staff in order to promote the appreciation and adherence to the standards recommended by the institution (1) , as well as the monitoring of this process through well-defined instruments.
In this way, it is clear that the Intervention is an influential strategy in the valuation of nurses about the presence and completeness of these records. However, a study using interrupted time series analysis showed that the quality performance decreased after the evaluative stage of accreditation (17) . Thus, management mechanisms with a view to assuring the quality and safety of care should be implemented on a permanent basis and assessed in order to strengthen the safety culture in the institution and evidenced in the records to maintain the quality seal of the JCI.

Conclusion
In analyzing the quality of nursing documentation through the Q-DIO -Brazilian version, by comparing the period before and after the preparation for Hospital Accreditation, it was found that there was an improvement in the quality of these records. It is concluded that the