Validation of the american quality assessment model and performance improvement to the brazilian transplant*

Objective: To validate the quality assessment and performance improvement instrument of US transplant programs to the Brazilian reality. Method: Methodological study developed for semantic validation and cultural adaptation of the Quality assessment and Performance Improvement instrument in the following steps: 1) translation; 2) synthesis; 3) back translation; 4) review by expert committee; 5) pretest and 6) content validation. To evaluate the agreement between the five judges, the Kappa coefficient was used and for content validation, the content validation index. Results: Kappa coefficient showed the agreement of the judges for semantic, idiomatic, cultural and conceptual equivalences. Content validation index values for relevance and item sequence of at least 0.80 for all blocks. Conclusion: The instrument of Quality Evaluation and Performance Improvement of Transplantation Programs proved to be valid and reliable. This instrument will contribute to the development of quality assurance programs for transplant teams in Brazil.


Introduction
The World Health Organization (WHO) in recent years has developed and encouraged the development of quality programs in health institutions with the principle that each person has the right to receive the best possible care, equally (1)(2) . Thus, WHO has taken a leading position in facilitating and scaling up different approaches to quality within the health system. Additionally, in most countries, quality is considered a strategic component, regardless of the level of economic development or the type of health system (1)(2) . Therefore, we must overcome the conception that considers the discourse of quality as the prerogative of rich countries with an advanced health system. Thus, quality in health care today is part of the national and international agenda and is present in the debates on health system reform.
Despite this fact, Brazil does not have a quality program or policy for the process of organ and tissue donation and transplantation that can determine the causes of losses due to underreporting, maintenance and family refusal, as a result of the care process, and indicators. pre and post-transplant outcome as well as patient survival (3) . Even so, in 2017, Brazil performed 5,929 kidney transplants and 2,109 liver transplants (4) , In 2017, the State of Santa Catarina achieved the highest effective donation rate in the country, with 40.8 parts per million population (pmp), followed by the state of Paraná with 38.0 pmp (4) . Despite national advances in organ donation and transplantation, investments in transplantation system research and auditing are needed to improve the quality of organ donation and transplantation processes, increase patient quality of life, and reduce costs and increased patient safety (6)(7) .  pretesting and content validation.
The translation was performed from the original instrument by two professionals with mastery of the Brazilian Portuguese language, one professional in translation and one health professional (9) . From both versions, the synthesis was generated by the researcher and judges.
After the synthesis, the Portuguese-language instrument was translated to the source language by two translators, one American health professional and one native speaker of the English language, and thus the new English version was compared to the original version (back-translation) (9) . After the instrument had To be considered national references in the area of transplantation, professionals with more than two years of experience in organ transplant management, with academic experience and validation of research instruments and mastery of the American English language were selected.
A first evaluation was performed by the experts about the content of the questionnaire descriptively and from their considerations. Secondly, content validation was performed using a Likert scale, (10) graded from "one" to "five", between totally disagree to totally agree, respectively. The following items typical of the culture of the place and, finally, the conceptual equivalence, that is, as the concept required in the questionnaire (11)(12) .
To perform content validation, the Content Validity were considered relevant, with variability from "one" to "five" and items above 0.8 (12) .
After the evaluations of the instrument made by the five judges, the final version for the pilot test was generated, adopting each consideration made, and the statistical analysis of the data was performed by calculating the Kappa coefficient (13) for multiple judges.
Some teams were in the implementation phase of indicators and others did not have them. Professionals from the city of São Paulo and inland were easier to answer the instrument without question. However, 20% of professionals did not answer the questions related to adverse events, as the program did not have the data.

Discussion
Quality management is currently being discussed in health care as a key to transplant outcomes and is beginning to integrate research and add value to patient care. It is expected to promote quality care in the routine of transplant centers with practices defined by the quality management model (14)(15)