Overview of (inter)national accreditation in Brazil

ABSTRACT

Objective

to outline the panorama of national and international Accreditation in Brazil.

Method

a descriptive study, of quantitative approach and documental source. The survey fields were the unrestricted access online pages of the following accrediting methodologies: National Accreditation Organization (ONA), Joint Commission International (JCI), Accreditation Canada International (ACI), and QMentum International, besides the page of the National Registry of Health Establishments (CNES) and/or institutional sites. Variables were extracted: type of institution/health care facility; sector management regime; location; level of certification (in case of a seal granted by ONA), and size (for hospitals). Descriptive statistical analysis was used.

Results

data from 1,122 certifications was obtained, especially from ONA (77.2%) and QMentum International (13.2%). Hospitals prevailed in the Accreditation adherence (35.3%), mainly the large ones (60.3%) and from the private sector (75.8%). There was a concentration of quality seals in the Southeast region of Brazil (64.5%), and the North region presented the lowest proportion of certified establishments (3%).

Conclusions and implications for practice

the Accreditation certifications in Brazil refer to the national methodology, focusing on the private hospital area and the Southeast region of the country. The mapping outlined can support assertiveness in incentive policies for quality management and external evaluation in Brazil.

Keywords:
Accreditation; Health Care Quality Assurance; Health Management; Hospital Administration; Total Quality Management

RESUMO

Objetivo

delinear o panorama da Acreditação nacional e internacional no Brasil.

Método

estudo descritivo, de abordagem quantitativa e fonte documental. Os campos de inquérito foram as páginas online de acesso irrestrito das seguintes metodologias acreditadoras: Organização Nacional de Acreditação (ONA), Joint Commission International (JCI), Accreditation Canada International (ACI) e QMentum Internacional, além da página do Cadastro Nacional de Estabelecimentos de Saúde (CNES) e/ou sites institucionais. Foram extraídas as variáveis: tipo de instituição/estabelecimento de saúde; regime de gestão setorial; localidade; nível de certificação (em caso de selo concedido pela ONA) e porte (para hospitais). Empregou-se análise estatística descritiva.

Resultados

apuraram-se os dados de 1.122 certificações, especialmente da ONA (77,2%) e QMentum International (13,2%). Os hospitais prevaleceram na adesão à Acreditação (35,3%), principalmente os de grande porte (60,3%) e do setor privado (75,8%). Houve concentração dos selos de qualidade na região Sudeste do Brasil (64,5%), e a região Norte apresentou menor proporção de estabelecimentos certificados (3%).

Conclusões e implicações para a prática

as certificações de Acreditação no Brasil remetem à metodologia nacional, com enfoque na área hospitalar privada e na região Sudeste do país. O mapeamento delineado pode sustentar assertividade em políticas de incentivo à gestão da qualidade e avaliação externa no Brasil.

Palavras-chave:
Acreditação; Administração Hospitalar; Avaliação da Qualidade dos Cuidados de Saúde; Gestão da Qualidade Total; Gestão em Saúde

RESUMEN

Objetivo

delinear el panorama de la Acreditación nacional e internacional en Brasil.

Método

estudio descriptivo, con enfoque cuantitativo y fuente documental. Los campos de consulta fueron las páginas en línea de libre acceso de las siguientes metodologías de acreditación: Organización Nacional de Acreditación (ONA), Joint Commission International (JCI), Accreditation Canada International (ACI) y QMentum Internacional, además del Registro Nacional de Establecimientos Salud (CNES) y/o sitios web institucionales. Se extrajeron las variables: tipo de institución/establecimiento de salud; régimen de gestión sectorial; localidad; nivel de certificación (en caso de sello otorgado por la ONA) y tamaño (para hospitales). Se utilizó análisis estadístico descriptivo.

Resultados

se recogieron datos de 1.122 certificaciones, especialmente de ONA (77,2%) y QMentum International (13,2%). Los hospitales prevalecieron en la adhesión a la Acreditación (35,3%), en especial los hospitales grandes (60,3%) y el sector privado (75,8%). Hubo concentración de sellos de calidad en la región Sudeste de Brasil (64,5%), y la región Norte tuvo la menor proporción de establecimientos certificados (3%).

Conclusiones e implicaciones para la práctica

las certificaciones de acreditación en Brasil se refieren a la metodología nacional, con foco en el área hospitalaria privada y la región Sudeste del país. El mapeo esbozado puede apoyar la asertividad en las políticas de fomento de la gestión de la calidad y la evaluación externa en Brasil.

Palabras clave:
Acreditación; Administración Hospitalaria; Garantía de la Calidad de Atención de Salud; Gestión de la Calidad Total; Gestión en Salud

INTRODUCTION

The health sector uses quality management in light of the basic assumptions of this managerial philosophy but adapts its strategies and tools in order to use them rationally, aiming to improve care and achieve organizational sustainability, which are peculiar aspects when compared to other service delivery branches. This adaptation and/or increase of improvement strategies includes the use of tools for situational diagnosis, action planning, and evaluation/monitoring of implemented processes and their results.¹

Quality evaluation needs to be based on reliable, pertinent, systematic, and applicable to reality instruments, such as indicators. In health care, indicators can be understood as synthetic measures to compile relevant information about certain elements, attributes, and dimensions of health status, as well as the performance and organization of a system or service.² Defining goals and standards regarding health indicators is important for the processes of health care quality assessment to leverage objectivity and, consequently, decision-making becomes more instrumentalized and assertive. In addition to being rational, such processes need to be participatory and cooperative.¹,³

Through quality standards, it is possible to compare whether the organizational performance is satisfactory so that the care provided is of excellence, aiming to offer safe health services, following a technical and scientific basis and, therefore, improving the care results.⁴,⁵ Standardizing health work is one of the precepts of Accreditation,⁶,⁷ defined as the external, systematic, periodic, systemic and reserved evaluation process, based on quality standards previously defined as optimal and that can generate a certification to the adherent services.⁴,⁶

It is expected that through its well-defined methods and tools and clearly defined standards - not to be confused with surveillance, licensing and/or certification - Accreditation will promote a culture of quality and safety, as well as permanent education that values the continuous improvement of services. In short, it should bring about positive changes and promote evidence-based clinical care and organizational activities that culminate in the advancement and constant evolution of health systems and services.⁴,⁶

A systematic review, with the objective of analyzing the impact of hospital Accreditation on the dimensions of quality in health care, assessed 36 primary studies and pointed out that Accreditation can have a positive impact on efficiency, safety, effectiveness, timeliness, and patient-centered care.⁷ Another review study, hosted by Indonesian researchers, which evaluated 11 primary research studies, inferred that improved management quality, worker participation in decisions, and improved care outcomes are positive points potentially attributable to Accreditation.⁸ However, in Brazil, the attributes favorable to patient safety have already been referred to as more visible in the moments across the visits for Accreditation certification, denoting that there are still gaps regarding the depth of institutional immersion into this robust quality management strategy.⁹ This means that the adherence to Accreditation should not be limited to the achievement of the seals/certificates that come from it, but, essentially, that its standards promote concrete improvements in the quality and safety of care and in the increase of management in health organizations, even if attributing causality to Accreditation is contradictory and challenging.⁹,¹⁰

Barriers/challenges in Accreditation implementation are somewhat frequently reported in the scientific literature. In Iran, inconsistencies and/or inadequate classification of standards, ambiguity of some quality metrics, incommensurable standards, vague and inflexible scoring system, and inability to use some standards are among the challenges recently reported.¹¹ In addition, insufficient financial resources, as well as lack of human resources, experience, and technology hinder the development and implementation of Accreditation systems, especially in underdeveloped or developing countries.¹²,¹³

In Brazil, the initiatives on Accreditation date from the late 1990s and early 2000s, in a spontaneous and voluntary way, that is, it is still a relatively recent management system in the country.¹⁴ Due to this non-mandatory characteristic, Brazilian health institutions can adhere to different accrediting methodologies, such as those of the National Accreditation Organization (ONA), Joint Commission International (JCI) and Accreditation Canada, for example.⁶,¹⁵

It is believed that knowing the national panorama of Accreditation in certified health institutions, both by national and international methodologies, can guide policies to stimulate quality management in Brazilian health and thus increasingly improve the quality of service to the population. With these factors in mind, this study was developed to answer the following question: “What is the Accreditation panorama among Brazilian health institutions that are nationally and internationally certified? To this end, the objective was to delineate the panorama of national and international Accreditation in Brazil.

METHOD

This is a descriptive study with a quantitative approach and a documental source. The survey fields were the free and public online pages of the following national and international accrediting methodologies: National Accreditation Organization (ONA),¹⁶ Joint Commission International (JCI),¹⁷ Accreditation Canada International (ACI)¹⁸ and QMentum Internacional.¹⁹

The accreditors were intentionally chosen in the knowledge that these are methodologies applicable to different types of health services and not to specific services (radiology, hemotherapy, oncology, etc.). Although both are Canadian models, we chose to differentiate between ACI and QMentum Accreditation because we verified, during the data collection process, divergences between them.

All information referring to the health institutions was computed, regardless of the type of service, level of complexity of care and/or management regime, which were available on the online public access pages of the investigated accrediting methodologies.¹⁶-¹⁹ The only eligibility criterion, therefore, was that the health care organization was duly registered on the accreditor's website during data collection. In case of double or triple Accreditation certification, all information was computed under the understanding that this is part of the desired panorama, i.e., that the interest of the study is to map the Accreditation certifications themselves. The online page of the National Registry of Health Establishments (CNES) and/or institutional sites (of the accredited services themselves) were also consulted to extract the necessary information, described as follows.

Data collection took place from January to May 2021, totally digitally. Electronic spreadsheets were used, which were divided into tabs built for the extraction of the following variables/categories, per institution/health care facility, according to each accrediting methodology (ONA, JCI, Accreditation Canada, and QMentum):

1) Type of health institution/establishment: hospital; doctor's office, clinic or polyclinic and outpatient services; land mobile unit; home care; diagnostic-therapeutic support unit; Basic Health Unit; Emergency Room; Day Hospital; Other (category that agglutinated other less prevalent services, such as mixed unit, supply center, pharmacy and hemotherapy care center and not identified (NI); 2) Sectorial management regime of the health institution/establishment: public, private or philanthropic sector; 3) Locality of the health institution/establishment: described by Brazilian regions (North, Northeast, Midwest, Southeast and South). Additionally, the following subcategories of variables: 4) Level of certification: was extracted from those institutions certified by ONA, which levels the certification in Accredited, Full Accredited and Accredited with Excellence and 5) Size: computed for establishments defined as hospitals and categorized as small (up to 50 beds), medium (51 to 150 beds), large (151 to 500 beds)²⁰ and extra capacity (above 500 beds).

Due to the expected divergences between the accreditors with regard to nomenclatures, the definition of the variable categories was made in a group in which the data collectors presented proposals that were collectively validated among the researchers, led by two PhDs in Nursing and teachers/researchers in the area of Health Management and Nursing.

The data tabulated in electronic spreadsheets were submitted to descriptive statistical analysis using Microsoft Office Excel® software. The variables, which were all categorical, were expressed in absolute and relative frequencies (%). The study complies with the appropriate ethical assumptions and did not need to be submitted to the Research Ethics Committee, according to Resolution 466/2012 of the National Health Council. However, the project was submitted and approved by a Research Committee of the Academic Unit where the responsible researcher works.

RESULTS

Data was collected on 1,122 Accreditation seals among the Brazilian institutions certified by one or more of the national and international accreditors surveyed. The frequency of national Accreditation, that is, the one made possible by ONA, exceeded the sum of the other investigated international accreditors as shown in Table 1.

Table 1
Distribution of Accreditation certifications in Brazil by accreditation methodology surveyed. Brazil, 2021. (N=1.122)

Accreditation Methodology	n (%)
National Accreditation Organization	867 (77.2)
Joint Commission International	63 (5.7)
Accreditation Canada International	43 (3.9)
QMentum International	149 (13.2)
Total	1,122 (100)

• Source: Prepared by the authors.

The type of service among the accredited facilities is presented in Table 2, which shows the prevalence of hospitals in relation to the other services. The diagnostic-therapeutic support units and the offices, clinics and outpatient clinics were the establishments with the second and third highest frequency of Accreditation adherence, respectively.

Table 2
Distribution of certifications by type of health facility and accrediting methodology. Brazil, 2021. (N=1,122)

Accreditation Methodology
Type of Healthcare Establishment	ONA	JCI	ACI	QMentum	General
	(n=867)	(n=63)	(n=43)	(n=149)	(N=1,122)
	n (%)	n (%)	n (%)	n (%)	n (%)
Hospital	309 (35.6)	40 (63.5)	33 (76.7)	14 (9.4)	396 (35.3)
Diagnostic and Therapeutic Support Unit	231 (26.6)	1 (1.6)	-	68 (45.6)	300 (26.7)
Doctor's Office, Clinic or Polyclinic and outpatient services	206 (23.7)	16 (25.4)	8 (18.6)	49 (32.9)	279 (24.9)
Day Hospital	33 (3.8)	0 (0)	2 (4.7)	2 (1.3)	37 (3.3)
Home Care	11 (1.2)	5 (7.9)	-	-	16 (1.4)
Primary Health Care Unit	2 (0.2)	-	-	9 (6)	11 (1.0)
Emergency Room	10 (1.1)	-	-	-	10 (0.9)
Land Mobile Unit	-	1 (1.6)	-	1 (0.7)	2(0.2)
Others*	29 (3.3)	-	-	6 (4)	35 (3.1)
Not identified	36 (4.1)	-	-	-	36 (3.2)

• ONA - National Accreditation Organization; JCI - Joint Commission International; ACI - Accreditation Canada International; QMentum – Qmentum Accreditation;
• ^*
  Includes Hemotherapy Care Center, Pharmacy, Mixed Unit and Supply Center. Source: Prepared by the authors.

Table 3 illustrates the other variables surveyed, pointing out that the institutions certified by Accreditation were concentrated in the Southeast region of Brazil and were mostly from the private sector. Moreover, among the hospitals, the large ones stood out, and among the institutions accredited by ONA, the level of excellence.

Table 3
Distribution of certifications for each accrediting methodology, by region of Brazil, management/funding regime, size, and certification level. (N=1,122)

Accreditation Methodology
Variable	Categories	ONA	JCI	ACI	QMentum	General
		n (%)	n (%)	n (%)	n (%)	n (%)
Region of Brazil (n=1,122)	North	25 (2.9)	1 (1,6)	2 (4,7)	6 (4,0)	34 (3)
	Mid-west	88 (10.1)	6 (9,5)	2 (4,7)	16 (10,7)	112 (10)
	Northeast	102 (11.8)	8 (12,7)	4 (9,3)	19 (12,8)	133 (11,9)
	Southest	554 (63.9)	41 (65,1)	33 (76,7)	96 (64,4)	724 (64,5)
	South	98 (11.3)	7 (11,1)	2 (4,7)	12 (8,1)	119 (10,6)
Management / Financing Regime (n=1,122)	Public	80 (9.2)	2 (3,2)	4 (9,3)	14 (9,4)	100 (8,9)
	Private	661 (76.2)	42 (66,7)	24 (55,8)	123 (82,6)	850 (75,8)
	Philanthropic	95 (11)	19 (30,2)	15 (34,9)	12 (8,1)	141 (12,6)
	Not identified	31 (3.6)	-	-	-	31 (2,8)
Port (Hospitals) (n=500)	Small	77 (22)	3 (7,3)	3 (8,6)	4 (5,4)	87 (10,8)
	Medium	136 (38.9)	10 (24,4)	5 (14,3)	18 (24,3)	169 (25,5)
	Large	128 (36.6)	24 (58,5)	27 (77,1)	51 (68,9)	230 (60,3)
	Extra capacity	9(2.6)	4(9,8)	-	1 (1)	14 (3,4)
Certification Level (ONA) (n=867)	Accredited	213 (24.6)
	Fully Accredited	259 (29.9)
	Accredited with Excellence	372 (42.9)
	Qualification Seal	23 (2.7)

• ONA - National Accreditation Organization; JCI - Joint Commission International; ACI - Accreditation Canada International; QMentum – Qmentum Accreditation. Source: Prepared by the authors.

Figure 1 reinforces, in a more illustrative way, the distribution of the establishments among the regions of Brazil, showing the lowest proportion of accredited institutions in the Northern region of the country. The Mid-West, Northeast, and South regions have similar proportions.

Figure 1
Map of the proportional distribution of health establishments adherent to Accreditation in Brazil, by region.

DISCUSSION

The higher concentration of hospitals adhering to Accreditation is an expected finding when considering the history of quality management in health care in Brazil and worldwide, which is evidently marked by this type of establishment as the cradle of the assumptions of external evaluation, process standardization and quality certification.¹⁴ This idea is confirmed by the fact that the name of the current JCI, in the early 1950s, was known as the Joint Commission of Accreditation of Hospitals (JCAH), that is, an organization directed to Accreditation and to hospital administration itself, which already had a connotation of voluntariness in the evaluation process.²¹

In a historicity based on the scarce scientific literature regarding the object under study, it is possible to allude that the adherence to Accreditation in Brazil seems to be exponential. By March 2017, ONA had 255 accredited hospitals in the country, followed by the ACI model, with 48, and 32 certifications by JCI.²² According to the cited study, this represented an increase, from October 2014 to March 2017, of 23.18% in the number of hospitals accredited by ONA.²² When bringing this analysis to the current data, one realizes that “only” among hospitals sealed by the national methodology, the growth in absolute numbers from 2017 to 2021 was 54 hospital organizations, which represents an average of 13.5 certifications/year more in the period and a growth of 21.1%.

Despite the growth verified regarding accredited hospitals, it is worth problematizing the number of certified hospital organizations in the portrait made possible by this study on the gross value of institutions of this same type in Brazil. Based on data from the National Health Establishments Registry (CNES), in September 2021, Brazil had 6,424 registered hospitals among general (n=5,434) and specialized institutions (n=990).²³ That is, the number of accredited hospitals (n=396) surveyed by this study represents only 6.1% of the estimated total number of hospitals in the country, an increase of less than 5% of what was reported five years ago by other Brazilian researchers.²³ This points out that there is still ample room for the dissemination of Accreditation in Brazil if this system gathers enough evidence to justify the improvement of the quality of care and sustainability in health management.

While it is reasonable to consider adherence to Accreditation in Brazil embryonic, it is prudent to assume that this research did not compile data from other models/types of external quality certifications. One example is the Commitment to Quality Hospital Program (CQH), based in the state of São Paulo, and which seeks to promote benchmarking and strategies to improve management and care. Another example is the National Integrated Accreditation for Healthcare Organizations (NIAHO).²⁴ However, considering the possible regionalization of the first example and the little national dissemination of the second, it is considered that this research represents a solid situational diagnosis regarding external quality certifications in Brazilian health.

The “low” adherence of Accreditation in Brazil becomes even more evident when viewed from the perspective of the financing models/systems of health care facilities, since the public sector presented less than 10% of the quality seals. With this study, the tendency of the private sector to concentrate the largest proportion of certified institutions is evident, which may be a product of the advance in marketing and potential competitive advantage that Accreditation can leverage for interested institutions.⁹,¹⁰

In addition to the potential marketing evidenced by the social projection of the service with external quality certification, organizational sustainability may be a factor that drives health care organizations to seek Accreditation. About this, a systematic review study, conducted by researchers based in the Netherlands and Saudi Arabia, analyzed 76 primary research studies, and among these, eight referred to potential positive impacts of Accreditation on economic results, such as increased process efficiency, cost reduction, and revenue increase.¹⁰

Even in the face of the positive aspects arising from the improvement and standardization of processes, in addition to the potential feeling of pride of the professionals of accredited institutions, it is worth pointing out that the Accreditation processes may mean pressure for goals and greater demand for results among the nurses, causing tension and wear on these professionals. A study that evaluated the association between muscle pain, stress, and resilience of nurses during the Accreditation maintenance process, did not find any correlation between the variables studied, but identified a higher resilience capacity after the assessment, indicating that the stressors experienced during the process were faced in an adequate manner, constituting a positive factor for the maintenance of the professionals' health and quality of care.²⁵

Despite the already mentioned prevalence among hospitals in the list of accredited Brazilian establishments, it is noted that the Therapeutic Diagnostic-Support Units - which represented a computation of services that aid in the determination of diagnosis and/or complement the treatment and rehabilitation of the patient - and the clinics, polyclinics, and outpatient clinics accounted for about a quarter of the total number of certifications. Even if the survey did not make this distinction in the analysis (which can be interpreted as a limitation), it is hypothesized that these establishments concentrate a high proportion of the private sector, since it is possible that they are institutions with a clear market interest in health.

Over the years, health services have faced the great challenge of increasing the quality of care and decreasing costs. Therefore, it is necessary to develop strategies and management models capable of meeting the needs of internal and external customers, associated with organizational sustainability.²⁶ A possible theoretical model capable of meeting this need is value-based health care. It is a model in which value is defined by the equation: quality of care provided to the patient divided by the cost spent by the institution to reach the best clinical outcome.²⁷

The high proportion of accredited large hospitals evidenced in this study demonstrates that the tertiary care system - a highly complex system that has resources, investments, and specialized labor - is seeking to provide better quality care. To accomplish this, it uses Accreditation as a marketing strategy to encourage potential users to consume its services, serve as a differentiation among providers and gain competitive potential.⁹,²⁸ Although this is important and necessary for organizational sustainability, it is important to reinforce that quality and safety of care deserve to be repeatedly put as the drivers of health quality strategies, systems and certifications, which may put the real benefits of Accreditation in question. About this, a study conducted with data from 4,242,684 inpatients in 4,400 hospitals in the United States inferred that hospital Accreditation in the country was not associated with lower mortality and was mildly associated with lower readmission rates for the 15 selected medical conditions. In addition, the survey reported that there was no evidence that patients choosing a JCI accredited hospital conferred any health benefits compared to choosing a hospital accredited by another organization.²⁴

The ONA has, in its evaluation, the certification related to four categories: Accredited, Full Accredited, Accredited with Excellence and Qualification Seal, each with different requirements. The Qualification Seal is intended for support services to health organizations, such as, for example, the material and sterilization center, nutrition, and laundry.²⁹ For the institution to obtain the first level (Accredited), it is necessary to meet 70% or more of the quality and patient safety standards in all active areas of the institution, including care and structural aspects. The Full Accredited level needs to maintain the same standards required at the previous level plus the presentation of an integrated management, with more fluid processes and full communication among the activities. The duration of Accreditation, for both levels, is two years with maintenance visits every eight months.²⁹

At the Accredited with Excellence level, the standards are more complex and directed at institutional management, since the entire process is already under development and, therefore, institutional maturity must be demonstrated to the evaluators. The processes must be carried out proactively and the organizational culture of improvement must be continuous. The Accreditation is valid for three years, with annual maintenance visits.²⁹ The level Accredited with Excellence was prevalent among the data from this survey related to the certifications issued by the ONA. When considering the voluntary characteristic of Accreditation in Brazil, one hypothesis to explain this finding is the possibility that the institutions that opt for Accreditation follow exponentially, adhering to the precepts of quality management and strategic management, that is, reaching higher levels of care and management quality compatible with the level of excellence.

In relation to international methodologies, QMentum stood out. Some of the characteristics of this accreditor are: Clinical Governance; Knowledge Management & Quality Dimensions; High Performance Teams and ROPs - a set of practices that provide direct linkage between the organization's knowledge, strategy, quality and safety of care.¹⁸ As for JCI-mediated Accreditation, it is based on principles such as: shaping best practices and establishing the most rigorous standards to raise performance standards; working with thousands of organizations worldwide, resulting in a powerful perspective when it comes to health care quality improvement and patient safety; and helping to attract and retain the best professionals who prefer to work in a place committed to health care quality.¹⁴,¹⁷

It is important to highlight that the sum of international certifications did not reach half of the seals issued by the national entity. It is hypothesized that this may be due to the greater feasibility of a methodology contextualized to the Brazilian scenario and/or to economic interests involved that is, a possible greater accessibility in the adhesion to a methodology located in the country itself and with lower costs, considering the process as a whole.

As to the geographical distribution of Accreditation in Brazil, it was possible to verify the expressive concentration in the Southeast region. A possible interpretation for this difference being so significant is the financial factor involved in joining the Accreditation process. The Southeast region concentrates three of the five cities with the highest GDP in Brazil, which are: São Paulo (SP), Rio de Janeiro (RJ) and Belo Horizonte (MG). In addition, it concentrates the largest number of health facilities in the country, representing 44.32% of the total 354,427.³⁰,³¹ This discrepancy in the distribution of health services is certainly related to the demographic density of the country. However, the encouragement of policies and strategies to improve the quality of health care deserves to be a factor of wide national dissemination.

The absence of inferential statistical analysis is perhaps the most significant limitation of this study. On the other hand, the clarity of the results suggests some differences with potential statistical significance, especially the concentration of the private sector, the national certification methodology and the Southeast region as the clear holders of Accreditation in Brazil. Despite the limitations, it is considered that this study permeates a robust diagnosis regarding one of the main management strategies for quality in healthcare today in a developing country.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The conclusion is that the Accreditation panorama in Brazil refers to the national methodology, focusing on large hospitals in the private sector and in the Southeast region of the country. After the hospital area, the most adherent organizations to external certification are the diagnostic-therapeutic support units and the medical offices/outpatient services.

Although it was not specifically an objective of this study, it was still possible to deduce that Accreditation is embryonic in the country, if the number of certified health services is projected over the non-certified ones. The whole panorama outlined may give rise to debates about possible strategies necessary for a greater dissemination of external quality certification in Brazilian health. For this, it is considered that the interest of the public power and the evaluation initiatives aligned and feasible to the reality of several types of services, in addition to the extrapolation of the Accreditation to all the regions of the country, seem to present themselves as spaces to be explored for a greater diffusion of this quality management system in the country. However, it is recommended that the political-organizational strategies potentially envisioned on the outlined panorama are not dissociated from a greater knowledge about the real benefits of Accreditation and the characteristics that the country intends to adhere to in relation to it.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  19 Sept 2022
• Date of issue
  2022

History

• Received
  18 Mar 2022
• Accepted
  01 Aug 2022