Accreditation in a public hospital: perceptions of a multidisciplinary team

Nadia Raquel Suzini Camillo João Lucas Campos de Oliveira José Aparecido Bellucci Junior Andressa Hirata Cervilheri Maria do Carmo Fernandez Lourenço Haddad Laura Misue Matsuda About the authors

RESUMO

Objetivo:

analisar as percepções da equipe multiprofissional sobre a Acreditação em um hospital público.

Método:

pesquisa descritiva, exploratória, de abordagem qualitativa, realizada em maio de 2014, por meio de entrevista individual gravada. Participaram 28 trabalhadores de um hospital público, Acreditado com Excelência, que responderam à questão norteadora: "Fale-me do sistema de Acreditação implantado neste hospital". As entrevistas foram transcritas na íntegra e submetidas a análise de conteúdo temática.

Resultados:

das falas, emergiram três categorias: Vantagens proporcionadas pela Acreditação; Hospital público acreditado assemelha-se com hospital privado e; Orgulho/satisfação por atuar em hospital público acreditado.

Conclusão:

os participantes percebiam a Acreditação como sistema favorável à gestão da qualidade no serviço público porque promove o desenvolvimento de competências profissionais e melhora a gestão de custos, a estrutura da organização, o gerenciamento da assistência e a percepção de orgulho/satisfação no trabalho.

Descritores:
Acreditação; Equipe de Assistência ao Paciente; Gestão da Qualidade; Hospital Público; Enfermagem

RESUMEN

Objetivo:

analizar las percepciones del equipo multiprofesional sobre la Acreditación de un hospital público.

Método:

investigación descriptiva, exploratoria, de abordaje cualitativo, realizada en mayo de 2014 a través de entrevistas individuales grabadas. Participaron 28 trabajadores de un hospital público, Acreditado con Excelencia, que respondieron a la cuestión orientadora: "Hábleme del sistema de Acreditación implantado en este hospital". Las entrevistas fueron transcriptas integralmente, y sometidas a análisis de contenido temático.

Resultados:

de los testimonios, emergieron tres categorías: Ventajas proporcionadas por la Acreditación; Un hospital público acreditado se asemeja a un hospital privado; y Orgullo/satisfacción por desempeñarse en un hospital público acreditado.

Conclusión:

los participantes entendían a la Acreditación como un sistema favorable para la gestión de calidad en el servicio público, pues promueve el desarrollo de competencias profesionales y mejora la gestión de costos, la estructura organizacional, el gerenciamiento de la atención y la percepción de orgullo/satisfacción por el trabajo.

Descriptores:
Acreditación; Grupo de Atención al Paciente; Gestión de la Calidad; Hospital Público; Enfermería

ABSTRACT

Objective:

to analyze the perceptions of the multidisciplinary team on Accreditation in a public hospital.

Method:

descriptive, exploratory, qualitative research, performed in May 2014, using recorded individual interviews. In total, 28 employees of a public hospital, Accredited with Excellence, answered the guiding question: "Tell me about the Accreditation system used in this hospital". The interviews were transcribed and subjected to content analysis.

Results:

of the speeches, three categories emerged: Advantages offered by the Accreditation; Accredited public hospital resembling a private hospital; Pride/satisfaction for acting in an accredited public hospital.

Conclusion:

participants perceived Accreditation as a favorable system for a quality management in the public service because it promotes the development of professional skills and improves cost management, organizational structure, management of assistance and perception of job pride/satisfaction.

Descriptors:
Accreditation; Patient Care Team; Management of Quality; Public Hospital; Nursing

INTRODUCTION

In health, the quality of services is designed to be polyssemic, complex, and often subjective(11 Rocha ESB, Trevisan MA, Júnior KR, Souza MC. Quality management in brazilian nursing: a literature review. Rev Enferm UERJ [Internet]. 2014[cited 2015 Mar 03];21(6):812-7. Available from: http://www.e-publicacoes.uerj.br/ojs/index.php/enfermagemuerj/article/view/12299/9577
http://www.e-publicacoes.uerj.br/ojs/ind...
), and should be problematized mainly from the management perspective. In this context, to enable assistance to the qualified health, it is indispensable to incorporate the organizational purposes with the needs of the consumers, by providing them services that offer security and satisfaction(22 Freitas JS, Silva AEBC, Minamisava R, Bezerra ALQ, Sousa MRG. Quality of nursing care and satisfaction of patients attended at a teaching hospital. Rev Latino-Am Enfermagem [Internet]. 2014[cited 2015 Mar 03];22(3):454-60. Available from: http://www.revistas.usp.br/rlae/article/viewFile/86599/89510
http://www.revistas.usp.br/rlae/article/...
-33 Pena MM, Melleiro MM. Degree of satisfaction of users of a private hospital. Acta Paul Enferm [Internet]. 2012[cited 2015 Mar 03];25(2):197-203. Available from: http://www.scielo.br/pdf/ape/v25n2/en_a07v25n2.pdf
http://www.scielo.br/pdf/ape/v25n2/en_a0...
).

In the health sector, managers systematically use assessment strategies, since this elementary management action tends to contribute to the achievement of the organizational objectives and also to the continuous improvement of services(33 Pena MM, Melleiro MM. Degree of satisfaction of users of a private hospital. Acta Paul Enferm [Internet]. 2012[cited 2015 Mar 03];25(2):197-203. Available from: http://www.scielo.br/pdf/ape/v25n2/en_a07v25n2.pdf
http://www.scielo.br/pdf/ape/v25n2/en_a0...
). Corroborating with this assertion, the authors(44 Haddad MCL, Évora YDM. Implantação do programa de qualidade em hospital universitário público. Ciênc Cuid Saúde [Internet]. 2012[cited 2015 Mar 03];11(4):78-86. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/17055
http://periodicos.uem.br/ojs/index.php/C...

5 Donabedian A. The seven pilars of quality. Arch Patol Clin Med. 1990;14(11):115-18.
-66 Alves AJ. O planejamento de pesquisas qualitativas em educação. Cad Pesq [Internet]. 2013[cited 2015 Mar 03];77(1):53-61. Available from: http://www.fcc.org.br/pesquisa/publicacoes/cp/arquivos/797.pdf
http://www.fcc.org.br/pesquisa/publicaco...
) defend that, particularly in health, quality and evaluation are concepts that interact with each other and, therefore, it is necessary to use them rationally and jointly in the day-to-day management of the institutions, be them public or private.

In the hospital context, Accreditation has been established as a process of external quality assessment of health services; it is a systematic, periodic and reserved method of assessing the institution, taking into account the dimensions of Structure, Process and Result, seen by the light of previously defined quality standards(55 Donabedian A. The seven pilars of quality. Arch Patol Clin Med. 1990;14(11):115-18.,77 Shaw CD, Braithwaite J, Moldovan M, Nicklin W, Grgic I, Fortune T, et al. Profiling health-care accreditation organizations: an international survey. Int J Qual Health Care [Internet]. 2013[cited 2015 Mar 03];25(3):222-31. Available from: http://intqhc.oxfordjournals.org/content/25/3/222.long
http://intqhc.oxfordjournals.org/content...
-88 Schiesari LMC. [External evaluation of hospital organizations in Brazil: could things be done differently]? Ciênc Saúde Colet [Internet]. 2014[cited 2015 Mar 03];19(10):4229-34. Available from: http://www.scielo.br/pdf/csc/v19n10/1413-8123-csc-19-10-4229.pdf Portuguese.
http://www.scielo.br/pdf/csc/v19n10/1413...
).

In Brazil, the Accreditation became more visible after 1999, year that marked the beginning of the National Accreditation Organization (Organização Nacional de Acreditação - ONA), a non-governmental, corporate and non-profit entity. The ONA assesses and (possibly) certifies the quality of health services, focusing on patient safety and the rational use of tools that support a continuous process of improvement(99 Organização Nacional de Acreditação. Manual das organizações prestadoras de serviços de saúde. Brasília (DF): ONA; 2014.-1010 Manzo BF, Brito MJM, Corrêa AR. [Implications of hospital accreditation on the everyday lives of healthcare professionals]. Rev Esc Enferm USP [Internet]. 2012[cited 2015 Mar 03];46(2):388-94. Available from: http://www.scielo.br/pdf/reeusp/v46n2/a17v46n2.pdf Portuguese
http://www.scielo.br/pdf/reeusp/v46n2/a1...
).

Accreditation certification issued by ONA can occur at three levels: Accredited (for institutions that meet minimum criteria for patient safety in all areas of activity, including structural and service aspects); Fully Accredited (for institutions that not only meet the safety criteria, but also have an integrated management, fluidity in the process and full communication between activities); and Accredited with Excellence (seeks "management excellence"), which meets the requirements of the two previous levels, and points to the existence of an organizational culture focused on continuous improvement(99 Organização Nacional de Acreditação. Manual das organizações prestadoras de serviços de saúde. Brasília (DF): ONA; 2014.).

Regardless of the level of certification validated by the ONA or other coexisting entities in Brazil, such as the Joint Commission International (JCI) or the model proposed by the Accreditation Canada (ACI), the Hospital Accreditation in Brazil is still an initiative that prevails among private institutions. This fact was observed in a recent study(1111 Sobrinho FM, Ribeiro HCTC, Alves M, Manzo BF, Nunes SMV. Performance em processo de acreditação de hospitais públicos de Minas Gerais/Brasil: influências para a qualidade de assistência. Enferm Global [Internet]. 2015[cited 2015 Mar 03];37(1):298-309. Available from: http://revistas.um.es/eglobal/article/viewFile/189511/169141
http://revistas.um.es/eglobal/article/vi...
) that found out that, of the total of 345 (100%) services accredited by ONA (the most common way), only 46 (13.3%) were in the public sector.

The aforementioned diverges from the reality of most socioeconomically developed countries, such as Australia, Canada, the United States, and Germany, where the Accreditation is increasingly encroaching on actions led by the government and, therefore, extends to health facilities managed by the public administration(77 Shaw CD, Braithwaite J, Moldovan M, Nicklin W, Grgic I, Fortune T, et al. Profiling health-care accreditation organizations: an international survey. Int J Qual Health Care [Internet]. 2013[cited 2015 Mar 03];25(3):222-31. Available from: http://intqhc.oxfordjournals.org/content/25/3/222.long
http://intqhc.oxfordjournals.org/content...
). Accreditation may even be required (including public services), as occurs in France, strongly recommended/encouraged by government agencies, as occurs in the United Kingdom(1212 Fortes MT, Mattos RA, Baptista TWF. Accreditation or accreditations? A comparative study about accreditation in France, United Kingdom and Cataluña. Rev Assoc Med Bras [Internet]. 2011[cited 2015 Mar 03];57(2):239-46. Available from: http://www.scielo.br/pdf/ramb/v57n2/en_v57n2a25.pdf
http://www.scielo.br/pdf/ramb/v57n2/en_v...
) and, also, to serve as a state regulatory tool, which is what occurs in Lebanon(1313 Fortes MT, Baptista TWF. Accreditation: tool or policy for health systems organizations? Acta Paul Enferm [Internet]. 2012[cited 2015 Mar 03];25(4):626-31. Available from: http://www.scielo.br/pdf/ape/v25n4/en_23.pdf
http://www.scielo.br/pdf/ape/v25n4/en_23...
).

We can see, thus, that the way Accreditation is used in other countries contrasts greatly to what is common in Brazil. Internationally, Accreditation is a totally voluntary, external evaluation system, free of state responsibility(88 Schiesari LMC. [External evaluation of hospital organizations in Brazil: could things be done differently]? Ciênc Saúde Colet [Internet]. 2014[cited 2015 Mar 03];19(10):4229-34. Available from: http://www.scielo.br/pdf/csc/v19n10/1413-8123-csc-19-10-4229.pdf Portuguese.
http://www.scielo.br/pdf/csc/v19n10/1413...
), which might be a strong reason for the reduced number of certifications granted to hospitals and other Brazilian public health services.

In addition to the small number of accredited public hospitals(88 Schiesari LMC. [External evaluation of hospital organizations in Brazil: could things be done differently]? Ciênc Saúde Colet [Internet]. 2014[cited 2015 Mar 03];19(10):4229-34. Available from: http://www.scielo.br/pdf/csc/v19n10/1413-8123-csc-19-10-4229.pdf Portuguese.
http://www.scielo.br/pdf/csc/v19n10/1413...
), the number of studies that address this theme in Brazil is also scarce. This fact was established through searches, performed in the last ten years (2005-2015), using online databases (Virtual Health Library - BVS, Scientific Electronic Library Online - SciELO, Latin American Literature in Health Sciences - LILACS, National Library of Medicine - PubMed, Nursing Database - BDENF, and Scopus), using only the controlled descriptor "hospital Accreditation" in both Portuguese and English. Most of the original research that deals with Accreditation use private hospitals as their field of study. In addition, no Brazilian based research was found, which focused on the perception of professionals working in the public service, dealing with the Accreditation system.

The lack of research addressing the theme of this study, together with the fact that Accreditation is a system that has the potential to leverage the quality of services(88 Schiesari LMC. [External evaluation of hospital organizations in Brazil: could things be done differently]? Ciênc Saúde Colet [Internet]. 2014[cited 2015 Mar 03];19(10):4229-34. Available from: http://www.scielo.br/pdf/csc/v19n10/1413-8123-csc-19-10-4229.pdf Portuguese.
http://www.scielo.br/pdf/csc/v19n10/1413...
) and to contribute to job satisfaction(1010 Manzo BF, Brito MJM, Corrêa AR. [Implications of hospital accreditation on the everyday lives of healthcare professionals]. Rev Esc Enferm USP [Internet]. 2012[cited 2015 Mar 03];46(2):388-94. Available from: http://www.scielo.br/pdf/reeusp/v46n2/a17v46n2.pdf Portuguese
http://www.scielo.br/pdf/reeusp/v46n2/a1...
), corroborates so that research focusing in the perspective of those who experience Accreditation may be a means of disseminating information regarding this search and/or facilitating adherence of other institutions into this system. Based on these arguments, we ask: "How do workers in a public hospital perceive the Accreditation system?" To answer this question, the objective of this study was to examine the perceptions of the multidisciplinary team on Accreditation in a public hospital.

METHOD

Theoretical and methodological frame of reference and type of study

The theoretical frame of reference of this study is guided by the Health Evaluation approach, based on the precepts of the donabedian triad mentioned above - Structure, Process, and Results -the pillars of quality in health(55 Donabedian A. The seven pilars of quality. Arch Patol Clin Med. 1990;14(11):115-18.), based on the understanding that the systemic optics and the systematic appreciation of the quality, seen through this frame of reference, support the principles of Accreditation(77 Shaw CD, Braithwaite J, Moldovan M, Nicklin W, Grgic I, Fortune T, et al. Profiling health-care accreditation organizations: an international survey. Int J Qual Health Care [Internet]. 2013[cited 2015 Mar 03];25(3):222-31. Available from: http://intqhc.oxfordjournals.org/content/25/3/222.long
http://intqhc.oxfordjournals.org/content...
,99 Organização Nacional de Acreditação. Manual das organizações prestadoras de serviços de saúde. Brasília (DF): ONA; 2014.).

Regarding the methodological frame of reference, for the processing and analysis of the data, we applied the Thematic Content Analysis technique(1414 Bardin L. Análise de conteúdo. Lisboa: Edições 70, 2011.), respecting the phases of pre-analysis, material exploration and processing of results. This technique was chosen for its potential to aid in the objective of this research and, together with the theoretical frame of reference, to provide direction and depth to the results and discussion.

This study is based on a descriptive and exploratory research, with a qualitative approach, yearning to achieve a thorough description, through subjective perspectives of the investigated object.

Scenario of the study

The survey was conducted in May 2014 in a public hospital in the state of Paraná, located in the metropolitan region of Curitiba (Brazil), which was certified by ONA as a hospital Accredited with Excellence. This institution was the first in southern Brazil to acquire such a certificate.

Data source

The study population consisted of all the professionals in the field of research, regardless of the category, hierarchical level and/or service. For the selection, the following criteria were used: being active in the hospital since at least the last audit of external evaluation for certification. The sample was non-probabilistic, established for convenience, with the number of participants based on the finding of the researcher, who was responsible for determining which interviews achieved the purpose set out beforehand.

Data collection and organization

The data collection occurred through individual interviews, recorded and guided by the statement: "Tell me about the Accreditation system implemented in this public hospital". The interviews were pre-scheduled according to the availability of each participant/ collaborator.

Data analysis

The interviews were transcribed and subjected to Content Analysis, in the thematic mode, respecting the steps of pre-analysis, material exploration, and data processing(1414 Bardin L. Análise de conteúdo. Lisboa: Edições 70, 2011.). In this process, all reports were repeatedly read, with common arguments highlighted and treated, always keeping with the original meaning of the words. The results shown after the semantic analysis of the content of the interviews were organized in thematic categories, according to the frame of reference used(1414 Bardin L. Análise de conteúdo. Lisboa: Edições 70, 2011.).

In presenting the results, excerpts/extracts/verbatim of the reports were edited to eliminate grammatical errors without, however, incurring in changes in the original content (i.e., the reports). In addition, whenever necessary, we added further compounded-terms in brackets to facilitate the understanding of the speeches by the reader.

Ethical aspects

At the beginning of the collection of data, the participant/collaborator received information about the objective of the study, the data collection procedure, and the ethical implications. Reading and signing a free consent form was the essential condition for the participation of the professional in the survey. To preserve the anonymity of the participants, the interviews were identified with the letter "I", followed by an Arabic numeral indicating the sequence of the interviews. Moreover, the ethical requirements set forth in the Resolution 466/2012 of the National Health Council were met and this research is registered under the CAAE number: 28867014.7.0000.0104, with an opinion issued by the Standing Committee on Research Ethics Involving Human Beings of the State University of Maringá, Paraná, Brazil.

RESULTS

In total, we interviewed 28 professionals of a multidisciplinary team, thus distributed: 8 nurses; 14 nursing technicians; 1 work safety technician; 1 leader of the hygiene and cleaning service; 2 pharmacists; 1 psychologist; 2 managers of hospital quality (responsible for the management of the Accreditation), one of them a nurse and the other a physical therapist.

Among the participants, females prevailed (23), aged between 22 and 48 years and with a minimum time of work in the hospital of 9 months and a maximum of 4.5 years. In the analysis of the interviews, three thematic categories were perceived: (1) Advantages offered by the Accreditation in a public hospital; (2) Accredited public hospital resembling a private hospital; and (3) Pride/satisfaction for working in an accredited public hospital.

Advantages offered by the Accreditation in a public hospital

According to the participants, the advantages arising from the Accreditation relate primarily to the requirements of ONA(99 Organização Nacional de Acreditação. Manual das organizações prestadoras de serviços de saúde. Brasília (DF): ONA; 2014.) since, in their speeches, they tend to point to improvements that cover areas of the hospital both in the managerial and the medical care areas. Given this core improvements, respondents mentioned that the advantages of the Accreditation certification provide public hospital service users an upgraded care, which is the result of the organization of the work process and the commitment of its employees.

Regarding the advantages attributed to the managerial core of this public hospital, the leadership exercised by managers is referred to as competent, for having achieved Accreditation, as can be noted in the excerpt:

I think it is important for a public hospital to get it [the Accreditation certification], because it shows the competence of the hospital management, of the leaders and all the staff to be able to achieve this certification. (I1)

In the following verbatim, participants emphasize that Accreditation, with the resultant benefits for the professionals, and also the benefits for the health service users, i.e. the patient:

[...] I think it [the Accreditation certification] is important. [...] it is important for the patient and for us. Anyway, for the SUS [Brazilian Unified Health System], which is a public system. (I1)

It is very good [the Accreditation], for us [workers] and for the patients. Working in a SUS hospital with Accreditation is good for us professionals and for the patients [...]. (I3)

Another aspect emphasized by the interviewees in this research refers to the constant advances in the Accredited public hospital to promote the search for improvements, which sets it above other hospitals that, even though are public, are devoid of this certification. In the following report, this search for progress is clearly evident:

I see that this hospital wants to grow always. The other [non-accredited public hospitals] stay stagnant. So, here there are always different things happening [...] a new protocol, always trying to improve something. The others remain stagnant. Here, since it's public, it is even better! (I20)

Among the benefits reported by participants of being part of the Accreditation, we have the organization of the work flow, and also the inclusion of services that support effective, fast, necessary, and sufficient diagnosis to meet the demands of its members.

Here [accredited public hospital], if you need an exam, they run after it, it's fast. If you need to have surgery, you get it done. So, it's a quick thing, that doesn't harm the patient. It is different from a public hospital that does not have the certification of Accreditation and, hence, have to chase after it [exams and surgeries] and wait. So, I find it very rewarding. (I10)

Another advantage of the certified public hospital refers to the comfort of the accommodations as a source of qualified health service:

[...] Being in the hall, having questions without answer, it's hard. And here, in this hospital [accredited public hospital], I see the difference: here there's quality, comfort! (I13)

Although the I14 and I16 excerpts refer to general aspects, participants also associate the existence of comfort and technology with the Accreditation:

[...] the hospital is public, but very well equipped [...]. (I14)

In the rooms, we have electric beds, TV, the patient is well attended in both hygiene and the accommodation part [...]. (I16)

The management practices of financial resources and the commitment of the professionals are also clearly marked by the respondents regarding the resulting benefits of the Accreditation process for the public hospital, also instigating the creativity of professionals in implementing actions that minimize costs:

[...] the Accreditation makes all the difference, just because we manage the cost of everything. All! For the clip I use to hold my papers, to the weight of the clothes to be washed, the liter [the amount] of water per patient [...] everything is transparent. There's nothing here that goes unnoticed. (I17)

[...] we do not have the financial resources to buy the bed that, the moment the patient disengages from the mattress, sends a signal to the nursing staff to prevent a fall. So we have to always think, create mechanisms and barriers to minimize the risks, in actions that do not result in much cost. (I25)

In keeping with the explained above and in the sense of valuing the advantages/benefits provided by the Accreditation in a public hospital, the improvement of the management of nursing care was mentioned:

It is important to show that we are in a public hospital, and, since it is accredited, we have 100% of electronic SAE [Systematization of Nursing Assistance] in the five stages and also the monthly sizing of the nursing staff, applied to the degree of complexity each patient brings. (I25)

Accredited public hospital resembling a private hospital

In the interviews, there is a description of similarities between accredited public hospitals and private hospitals, regarding the quality of care. These similarities can be linked to the advantages that the Accreditation certification provides the public hospital, as was discussed in the category above. The following speeches denote this statement:

[...] The people [the community] think we work in a private hospital and I say: not, guys, it is 100% SUS [...]. (I23)

The service in the hospital [accredited public hospital] can even be compared to a private hospital, within the specialty we treat in today. I'm always hearing people talking like this: our room, the service there is like a private hospital. So that's very good! (I15)

The conditions of service of the Brazilian public hospitals are also perceived as poor and in need of humanization. Also, we perceive the desire that these conditions could be improved by the Accreditation of all public hospitals. Thus, users who have unfavorable financial conditions could enjoy quality care, normally offered by the private sector, which is similar to that received by members of the Accredited public hospital included in the field of this study:

Look, how good it would be if all SUS hospitals were accredited, so those people who cannot afford [financially], have no health plan, or can't afford to have a particular care, can receive a better and more humanized care (I15).

Another speech emanating from the participants of this study, which shows the similarities of the Accredited public hospital to a private hospital, stands out in:

It is a hospital like any private hospital. I work at another hospital that is private and here [accredited public hospital] there's nothing left to be desired. Since it is a SUS hospital and accredited, care only tends to improve. (I21)

Pride/satisfaction for working in an accredited public hospital

In addition to the advantages resulting from the Accreditation process, the similarities between the public hospital and the private hospital service, the pride of being a part of the working staff of a public hospital certified by ONA, can be noted in the speech of the study participants.

The pride of working in an Accredited public institution, certainly corroborates the fact that the membership of the Accreditation encourages professionals to grow, as emphasized by the following account:

For me, there's pride in saying that I work in a level 3 public hospital. I feel honored of growing here. (I6).

In this same line of thought, another professional stated:

In my point of view, there is immense pride because, first this is a public hospital, and second, to have achieved the Accreditation, which is something very important for all hospitals. Then, joining the two things, we see that this is a very rare thing to occur. Anyway, for me, it is a very great pride. (I19)

It was also possible to see that professional pride of working in an accredited public service is linked with job satisfaction and user satisfaction:

I think it's wonderful [working in an Accredited public hospital]. Then, it [the process of Accreditation] brings a lot of satisfaction, both for those who work here, as well as those are treated at this hospital. (I22)

Professionals reported a sense of pride in working for the quality management system and seem to want to reach new stages/levels:

We are the first Accredited public hospital, Level 2 and Level 3 in the South of Brazil. This is a great pride [...]. Look, I am very proud of saying that today this hospital is Level 3, accredited by ONA and is seeking the JCI Accreditation [Joint Commission International]. I think the word is pride, really, to be part of this team. (I25)

[...] I'm very proud [to work in an Accredited public hospital]. It is a public hospital and a certified one. We accomplish this with a lot of work and if we could, all the others can achieve this. So, I'm proud to be here, really a motivation and a desire for it to proliferate throughout Brazil. (I28)

In the excerpts, we see that the certification process by the Accreditation demands work and dedication, but the resulting feeling is achievement.

DISCUSSION

The advantages arising from the certification by the Accreditation in a public hospital, are consistent with what is recommended by the ONA, especially in the first evaluation section of healthcare organizations(99 Organização Nacional de Acreditação. Manual das organizações prestadoras de serviços de saúde. Brasília (DF): ONA; 2014.). Thus, the Accreditation promotes the qualification of health services, with a focus on patient safety and the rational use of tools that support the continuous improvement process of the institution(99 Organização Nacional de Acreditação. Manual das organizações prestadoras de serviços de saúde. Brasília (DF): ONA; 2014.-1010 Manzo BF, Brito MJM, Corrêa AR. [Implications of hospital accreditation on the everyday lives of healthcare professionals]. Rev Esc Enferm USP [Internet]. 2012[cited 2015 Mar 03];46(2):388-94. Available from: http://www.scielo.br/pdf/reeusp/v46n2/a17v46n2.pdf Portuguese
http://www.scielo.br/pdf/reeusp/v46n2/a1...
).

Regarding the benefits at the management level, the leadership exercised by managers is referred to as competent for managing to achieve Accreditation, since during the period of certification, managers and employees must be committed to taking actions that will be reflected in the service qualification provided to the users. Thus, the skills attributed to the managers, allow for a continuous improvement of care, closely linked to actions of a participatory leadership, directed to the client(99 Organização Nacional de Acreditação. Manual das organizações prestadoras de serviços de saúde. Brasília (DF): ONA; 2014.,1515 Alves VLS. Gestão da qualidade: ferramentas utilizadas no contexto contemporâneo da saúde. 2. ed. São Paulo: Martinari; 2012.).

It will be important, therefore, that the Accreditation in public services promote a participative leadership, since it also corresponds to the principles of the Unified Health System (SUS), which values the partnership between managers, professionals, and users to plan feasibility strategies of effective, efficient, and humanized models of care(1616 Cecilio LCO. Colegiados de gestão em serviços de saúde: um estudo empírico. Cad Saúde Pública [Internet]. 2010[cited 2015 Mar 03];26(3):557-66. Available from: http://www.scielosp.org/pdf/csp/v26n3/13.pdf
http://www.scielosp.org/pdf/csp/v26n3/13...
). The certification advantages of an accredited public hospital possibly go beyond the relationship between managers and professionals, since they also benefit the users. In this perspective, the I3 and I1 excerpts denote that adherence to this system resulted in an increased quality.

It is worth mentioning SUS, regarding the benefits or improvements resulting from the Accreditation. This is important because, in Brazil, all actions in the education and health practice field are known to correspond to the dictates of this System.

We highlight the I20 notation, by pointing out the benefits provided by the Accreditation to the public hospital. This may be due to the contrast of reality punctuated by what is disseminated by communication channels, scientific productions, means that not infrequently describe public hospital services as outdated, overcrowded, and dysfunctional, especially in terms of structure(44 Haddad MCL, Évora YDM. Implantação do programa de qualidade em hospital universitário público. Ciênc Cuid Saúde [Internet]. 2012[cited 2015 Mar 03];11(4):78-86. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/17055
http://periodicos.uem.br/ojs/index.php/C...
,1717 Higashi P, Simonetti JP, Carvalhaes MABL, Spiri WC, Parada CMGL. Potentially stressful situations for nurses considering the condition of accreditation of hospitals. Rev RENE [Internet]. 2013[cited 2015 Mar 03];14(6):1141-8. Available from: http://www.revistarene.ufc.br/revista/index.php/revista/article/view/1343/pdf
http://www.revistarene.ufc.br/revista/in...
). In these terms, it is worth highlighting the cohesion between the findings and the proposed frame of reference adopted to their form of interpretation, by the recommendation that healthcare organizations be appreciated, even in the midst of its Structure. This, according to Donabedian(55 Donabedian A. The seven pilars of quality. Arch Patol Clin Med. 1990;14(11):115-18.), corresponds to the dimension of the assessment of "more stable" characteristics of the service, such as the physical, human, material, and financial resources.

An excerpt from I20 is also consistent with the proposal of the ONA(99 Organização Nacional de Acreditação. Manual das organizações prestadoras de serviços de saúde. Brasília (DF): ONA; 2014.), since it points to the Accreditation as a promoter of advances in patient safety through educational and innovative actions, providing care improvements that are effective, continuous and resolute in health institutions. This data should be highlighted, because in the Brazilian scenario, especially in public hospitals, there are long waiting lines for consultations and procedures(1717 Higashi P, Simonetti JP, Carvalhaes MABL, Spiri WC, Parada CMGL. Potentially stressful situations for nurses considering the condition of accreditation of hospitals. Rev RENE [Internet]. 2013[cited 2015 Mar 03];14(6):1141-8. Available from: http://www.revistarene.ufc.br/revista/index.php/revista/article/view/1343/pdf
http://www.revistarene.ufc.br/revista/in...
), but in the accredited hospital, according to I10, we see the opposite occurring.

Another advantage mentioned by the participants, also in the first theme category, refers to the comfort of the accommodation, which, according to the literature(1818 Oliveira SG, Quintana AM, Budó MLD, Morais NA, Garcia RP, Sartor SF, et al. Internação domiciliar na terminalidade: escolhas terapêuticas e medidas de conforto no olhar do cuidador. J Nurs Health [Internet]. 2014[cited 2015 Mar 03];3(2):221-32. Available from: https://periodicos.ufpel.edu.br/ojs2/index.php/enfermagem/article/view/3731
https://periodicos.ufpel.edu.br/ojs2/ind...
), constitutes an important factor for treatment efficiency. Working conditions, mediated by the physical structure, constitute a factor that relates to the qualification of the accredited hospital services, as denoted by the verbatim I10, I13, I14 and I1. However, attributing quality to a service solely by its structure can be immature and even counterproductive, since the quality is permeated by elements such as patient satisfaction and safety, aligned to the purposes of the organization(22 Freitas JS, Silva AEBC, Minamisava R, Bezerra ALQ, Sousa MRG. Quality of nursing care and satisfaction of patients attended at a teaching hospital. Rev Latino-Am Enfermagem [Internet]. 2014[cited 2015 Mar 03];22(3):454-60. Available from: http://www.revistas.usp.br/rlae/article/viewFile/86599/89510
http://www.revistas.usp.br/rlae/article/...
-33 Pena MM, Melleiro MM. Degree of satisfaction of users of a private hospital. Acta Paul Enferm [Internet]. 2012[cited 2015 Mar 03];25(2):197-203. Available from: http://www.scielo.br/pdf/ape/v25n2/en_a07v25n2.pdf
http://www.scielo.br/pdf/ape/v25n2/en_a0...
). This attitude confirms the donabedian reference of the Assessment in Health, which included, in addition to the structure, the dimensions of Process and Results(55 Donabedian A. The seven pilars of quality. Arch Patol Clin Med. 1990;14(11):115-18.).

In this perspective, we conjecture that, especially in the context of Accreditation, innovative actions by the management, that go beyond the structural issue, are necessary to achieve the objectives of the institution. This incurs, also, in the efficient management of the care process and the consequences for the organization and its members, in addition to the costs.

The verbatim expressed in I17, indicates that the Accreditation brings benefits to the institution's management of financial resources. In this sense, the Accreditation seems to be a contribution and/or guide to monitor hospital costs, contributing to the social responsibility that this management practice exerts in public services. This also refers to the assumptions of reference(55 Donabedian A. The seven pilars of quality. Arch Patol Clin Med. 1990;14(11):115-18.) of this research, which addresses the efficiency and optimization as pillars of quality of care, and the result of the proper use of funds by health institutions.

Still in management of hospital costs, the Accreditation in government services, not only denotes support to the social commitment, by properly managing the public money, but also tends to mobilize people for the exercise of creativity and citizenship. This occurs due to the cost management, which is an essential factor for the survival of the organization, whether public or private, and also due to the very process of certification, which is internationally recognized as expensive(1919 Jaafaripooyan E. Potential pros and cons of external healthcare performance evaluation systems: real-life perspectives on Iranian hospital evaluation and accreditation program. Int J Health Policy Manag [Internet]. 2014[cited 2015 Mar 03];3(4):191-8. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4181968/pdf/IJHPM-3-191.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles...
). Thus, in addition to the imposition of lower costs, in a way, the Accreditation, since its implementation(2020 Alástico GP, Toledo JC. Acreditação Hospitalar: proposição de roteiro para implantação. Gest. Prod. [Internet]. 2013[cited 2015 Mar 03];20(4):815-31. Available from: http://www.scielo.br/pdf/gp/v20n4/aop_gp128412.pdf
http://www.scielo.br/pdf/gp/v20n4/aop_gp...
), brings an important management of processes, involving all employees, that aims at improving quality as a whole, as highlighted in the I25 excerpt.

The hospital quality is a complex phenomenon, a relentless pursuit, in which managers need to focus on insuring a safe service and customer satisfaction(22 Freitas JS, Silva AEBC, Minamisava R, Bezerra ALQ, Sousa MRG. Quality of nursing care and satisfaction of patients attended at a teaching hospital. Rev Latino-Am Enfermagem [Internet]. 2014[cited 2015 Mar 03];22(3):454-60. Available from: http://www.revistas.usp.br/rlae/article/viewFile/86599/89510
http://www.revistas.usp.br/rlae/article/...
). Faced with this, we must consider the importance of the nursing staff in the acquisition of qualified assistance, since it is the only category that keeps with the patient/client 24 hours a day. It is referencing to this team that some lines will be highlighted bellow.

The I25 excerpt, in the first topic discussed, confirms the importance of the nursing staff regarding the qualification of the care and the improvement of its management (of assistance and of human resources), as an advantage of the Accreditation in the surveyed hospital. This is due to the fact that SAE is classically recognized as a management tool/instrument that provides scientificity and promotes quality in the work performed by nurses(2121 Soares MI, Resk ZMR, Terra FS, Camelo SHH. Systematization of nursing care: challenges and features to nurses in the care management. Esc Anna Nery Rev Enferm [Internet]. 2015[cited 2015 Mar 03];19(1):47-53. Available from: http://www.scielo.br/pdf/ean/v19n1/en_1414-8145-ean-19-01-0047.pdf
http://www.scielo.br/pdf/ean/v19n1/en_14...
).

No less important than the SAE, the systematic achievement of the dimensioning of the nursing staff in the institution is another factor to be highlighted, since it relates directly to quality and patient safety(2222 Magalhães AMN, Dall'Agnol CM, Marck PB. Nursing workload and patient safety: a mixed method study with an ecological restorative approach. Rev Latino-Am Enfermagem [Internet]. 2013[cited 2015 Mar 03];21(Spec):146-54. Available from: http://www.scielo.br/pdf/rlae/v21nspe/19.pdf
http://www.scielo.br/pdf/rlae/v21nspe/19...
). However, despite its importance, we have found that this practice does not always occur(22 Freitas JS, Silva AEBC, Minamisava R, Bezerra ALQ, Sousa MRG. Quality of nursing care and satisfaction of patients attended at a teaching hospital. Rev Latino-Am Enfermagem [Internet]. 2014[cited 2015 Mar 03];22(3):454-60. Available from: http://www.revistas.usp.br/rlae/article/viewFile/86599/89510
http://www.revistas.usp.br/rlae/article/...
). Therefore, the Accreditation can, once more, act as a guide for monitoring and enforcing compliance with previously defined standards, since this system requires a qualitative and quantitative adequacy of professionals(99 Organização Nacional de Acreditação. Manual das organizações prestadoras de serviços de saúde. Brasília (DF): ONA; 2014.), which, according to the literature(22 Freitas JS, Silva AEBC, Minamisava R, Bezerra ALQ, Sousa MRG. Quality of nursing care and satisfaction of patients attended at a teaching hospital. Rev Latino-Am Enfermagem [Internet]. 2014[cited 2015 Mar 03];22(3):454-60. Available from: http://www.revistas.usp.br/rlae/article/viewFile/86599/89510
http://www.revistas.usp.br/rlae/article/...
), has proved to be mostly lacking in nursing.

An excerpt from I25, in particular, reveals that the Accreditation in the public hospital contributed to the management of nursing care, led by the computerization process of SAE, which may have facilitated the necessary actions for personnel design, with a view to quality of care. This data corroborates with the literature(2323 Matsuda LM, Higarashi IH, Évora YDM, Bernardes A. Perception of nurses on the use of computer at the work. Rev Bras Enferm [Internet]. 2014[cited 2015 Mar 03];67(6):949-56. Available from: http://www.scielo.br/pdf/reben/v67n6/0034-7167-reben-67-06-0949.pdf
http://www.scielo.br/pdf/reben/v67n6/003...
), by pointing out that the use of computers by the nursing staff, has the potential of qualifying management and care.

Still regarding the consequences of the Accreditation for public health services, the quality of care is classically designed using Donabedian as a frame of reference, due to the way users (consumers) accept the care as being qualified. More precisely, it is a legitimation of individuals (donabedian pillar of acceptability), groups and society in general (donabedian pillar of legitimacy) regarding the service offered(55 Donabedian A. The seven pilars of quality. Arch Patol Clin Med. 1990;14(11):115-18.). In view of the current society perception of public services compared to the quality of care in health, some participants graded the hospital surveyed as similar to a private hospital, regarding the advantages offered by the Accreditation, i.e., indicate "higher" qualification.

We observed in the second thematic category, especially in the excerpt from I23, that the hospital under scrutiny seems to be legitimized by the population as being similar to a private institution. This possibly occurs in the light of the requirements by the Accreditation which, among others, dictates that the service should be adapted in structure(1111 Sobrinho FM, Ribeiro HCTC, Alves M, Manzo BF, Nunes SMV. Performance em processo de acreditação de hospitais públicos de Minas Gerais/Brasil: influências para a qualidade de assistência. Enferm Global [Internet]. 2015[cited 2015 Mar 03];37(1):298-309. Available from: http://revistas.um.es/eglobal/article/viewFile/189511/169141
http://revistas.um.es/eglobal/article/vi...
,2020 Alástico GP, Toledo JC. Acreditação Hospitalar: proposição de roteiro para implantação. Gest. Prod. [Internet]. 2013[cited 2015 Mar 03];20(4):815-31. Available from: http://www.scielo.br/pdf/gp/v20n4/aop_gp128412.pdf
http://www.scielo.br/pdf/gp/v20n4/aop_gp...
), something that is precarious in several Brazilian public hospitals of the same size(44 Haddad MCL, Évora YDM. Implantação do programa de qualidade em hospital universitário público. Ciênc Cuid Saúde [Internet]. 2012[cited 2015 Mar 03];11(4):78-86. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/17055
http://periodicos.uem.br/ojs/index.php/C...
,1717 Higashi P, Simonetti JP, Carvalhaes MABL, Spiri WC, Parada CMGL. Potentially stressful situations for nurses considering the condition of accreditation of hospitals. Rev RENE [Internet]. 2013[cited 2015 Mar 03];14(6):1141-8. Available from: http://www.revistarene.ufc.br/revista/index.php/revista/article/view/1343/pdf
http://www.revistarene.ufc.br/revista/in...
).

It is known that public hospital services are responsible for most of the population in need of high and average complexity care(44 Haddad MCL, Évora YDM. Implantação do programa de qualidade em hospital universitário público. Ciênc Cuid Saúde [Internet]. 2012[cited 2015 Mar 03];11(4):78-86. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/17055
http://periodicos.uem.br/ojs/index.php/C...
,1717 Higashi P, Simonetti JP, Carvalhaes MABL, Spiri WC, Parada CMGL. Potentially stressful situations for nurses considering the condition of accreditation of hospitals. Rev RENE [Internet]. 2013[cited 2015 Mar 03];14(6):1141-8. Available from: http://www.revistarene.ufc.br/revista/index.php/revista/article/view/1343/pdf
http://www.revistarene.ufc.br/revista/in...
). In this sense, it is important that these services be prepared to meet the demands in a qualified manner. According to one participant, this condition can be made possible by the Accreditation.

Another constant feature in I15's testimony should be considered. The participant indicates that public hospitals that do not adhere to the Accreditation are different from private hospitals, with a deficiency in the humanization of care. This is worrisome, because it emphasizes the precariousness in some aspects of the hospitals managed by the public administration, which leads the population, including health professionals, to sometimes believe private services are better.

Despite previous considerations, it should be recognized that studies have pointed to the satisfaction of patients in public hospitals not accredited as crescent(22 Freitas JS, Silva AEBC, Minamisava R, Bezerra ALQ, Sousa MRG. Quality of nursing care and satisfaction of patients attended at a teaching hospital. Rev Latino-Am Enfermagem [Internet]. 2014[cited 2015 Mar 03];22(3):454-60. Available from: http://www.revistas.usp.br/rlae/article/viewFile/86599/89510
http://www.revistas.usp.br/rlae/article/...
,2424 Schmidt SMS, Müller FM, Santos E, Ceretta OS, Garlet V, Schimitt S. Análise da satisfação dos usuários em um hospital universitário. Saúde Deb [Internet]. 2014[cited 2015 Mar 03];38(101):305-17. Available from: http://www.scielo.br/pdf/sdeb/v38n101/0103-1104-sdeb-38-101-0305.pdf
http://www.scielo.br/pdf/sdeb/v38n101/01...
). Also, a survey type research, conducted by German and Australian researchers, with 37,000 patients from 73 hospitals, showed no significant association between patient satisfaction and hospital accreditation(2525 Sack C, Scherag A, Lütkes P, Günther W, Jöckel KH, Holtmann G. Is there an association between hospital accreditation and patient satisfaction with hospital care? a survey of 37000 patients treated by 73 hospitals. Int J Qual Health Care [Internet]. 2011[cited 2015 Mar 03];23(3):278-83. Available from: http://intqhc.oxfordjournals.org/content/intqhc/23/3/278.full.pdf
http://intqhc.oxfordjournals.org/content...
).

According to the above, the reflection of the panorama of Brazilian public hospitals is proven to be peculiar, facing constant problems related to the lack of various resources. Since much of the clientele has low education levels and unfavorable socioeconomic conditions, there is a reduced level of required excellence regarding public health services(2424 Schmidt SMS, Müller FM, Santos E, Ceretta OS, Garlet V, Schimitt S. Análise da satisfação dos usuários em um hospital universitário. Saúde Deb [Internet]. 2014[cited 2015 Mar 03];38(101):305-17. Available from: http://www.scielo.br/pdf/sdeb/v38n101/0103-1104-sdeb-38-101-0305.pdf
http://www.scielo.br/pdf/sdeb/v38n101/01...
).

Excerpt from I21, relevant to the second category, corroborates with the others in the sense that the Accreditation is a factor that allows the public hospital to offer its users and professionals the same labor conditions and assistance offered by a private hospital. These situations contribute to the professionals' feelings of pride for working in certified public hospital, feeling even happy to be working in an institution that adheres to the system(1010 Manzo BF, Brito MJM, Corrêa AR. [Implications of hospital accreditation on the everyday lives of healthcare professionals]. Rev Esc Enferm USP [Internet]. 2012[cited 2015 Mar 03];46(2):388-94. Available from: http://www.scielo.br/pdf/reeusp/v46n2/a17v46n2.pdf Portuguese
http://www.scielo.br/pdf/reeusp/v46n2/a1...
), in accordance to what was discussed above. It is noteworthy, however, that this reality is not experienced by most professionals in public health institutions, since the certification process in question is significantly reduced in these places(1111 Sobrinho FM, Ribeiro HCTC, Alves M, Manzo BF, Nunes SMV. Performance em processo de acreditação de hospitais públicos de Minas Gerais/Brasil: influências para a qualidade de assistência. Enferm Global [Internet]. 2015[cited 2015 Mar 03];37(1):298-309. Available from: http://revistas.um.es/eglobal/article/viewFile/189511/169141
http://revistas.um.es/eglobal/article/vi...
).

The success of obtaining and maintaining certification by the Accreditation, demands hard work by the management and the multidisciplinary team, for it is necessary to overcome paradigms and incorporate growth strategies to the desired quality. Possibly, in addition to other factors, those mentioned above also contribute to the feeling of pride professionals have for being a part of the team of the accredited institution, with this condition generating satisfaction and joy in the workplace(1010 Manzo BF, Brito MJM, Corrêa AR. [Implications of hospital accreditation on the everyday lives of healthcare professionals]. Rev Esc Enferm USP [Internet]. 2012[cited 2015 Mar 03];46(2):388-94. Available from: http://www.scielo.br/pdf/reeusp/v46n2/a17v46n2.pdf Portuguese
http://www.scielo.br/pdf/reeusp/v46n2/a1...
).

The pride expressed in I6's testimony, noted in the third thematic category, can be considered as another arising advantage of Accreditation, linked to the fact he/she works in an accredited public hospital, and also to the feel of responsibility they feel in seeking to achieve certification(1010 Manzo BF, Brito MJM, Corrêa AR. [Implications of hospital accreditation on the everyday lives of healthcare professionals]. Rev Esc Enferm USP [Internet]. 2012[cited 2015 Mar 03];46(2):388-94. Available from: http://www.scielo.br/pdf/reeusp/v46n2/a17v46n2.pdf Portuguese
http://www.scielo.br/pdf/reeusp/v46n2/a1...
). This data can be a contributing factor to job satisfaction, linked to the theoretical construct(55 Donabedian A. The seven pilars of quality. Arch Patol Clin Med. 1990;14(11):115-18.), chosen to highlight findings. In the donabedian triad evaluation, job satisfaction is considered an important indicator of the dimension Results, since it tends to have a positive impact on quality of care.

Once more, the findings point to the favoring of Accreditation in public hospitals, linked to the satisfaction and pride of professionals with the satisfaction of the service's users. It follows, then, that this is an important relationship, since job satisfaction tends to reflect the quality of care and, therefore, the user/patient satisfaction(2626 Tenani MNF, Vannuchi MTO, Haddad MCL, Matsuda LM, Pissinati PSC. Work satisfaction of new lyhired nursing workers in a public hospital. Rev Min Enferm [Internet]. 2014[cited 2015 Mar 03];18(3):592-7. Available from: http://reme.org.br/artigo/detalhes/948
http://reme.org.br/artigo/detalhes/948...
-2727 Souza PC, Scatena JHG. Satisfação do usuário da assistência hospitalar no mix público-privado do SUS do Estado de Mato Grosso. Espaço Saúde. 2014;15(3):30-41.).

It is noteworthy, in I25 and I28 excerpts, the professional motivation derived from the service accredited with the highest level established by ONA (Level 3 - Accredited with Excellence). This motivation can be justified by the commitment and responsibility of the whole team of professionals and managers to achieving the highest level of certification. Thus, possibly due to the organization's maturity, the I25 testimonial points to the fact that the public hospital Accredited with Excellence intend to seek certification of international Accreditation, given by the Joint Commission International, recognized as the world's largest organization in terms of quality of care and patient safety(77 Shaw CD, Braithwaite J, Moldovan M, Nicklin W, Grgic I, Fortune T, et al. Profiling health-care accreditation organizations: an international survey. Int J Qual Health Care [Internet]. 2013[cited 2015 Mar 03];25(3):222-31. Available from: http://intqhc.oxfordjournals.org/content/25/3/222.long
http://intqhc.oxfordjournals.org/content...
).

Study limitations: We must allude to the considerations above, for they cannot be taken as conclusive and general truths, given that this research carries limitations, as well as its cross-sectional approach, with individual and single interviews and also the single reality explored. Therefore, we suggest further studies with different methodological approaches, such as quantitative analytical research, seeking to measure/compare, among other things, the management of financial resources, the satisfaction of users and professionals in different realities related to the Accreditation in the field of public health services.

Contributions to the fields of Nursing, health or public policy: We hope this study will foster discussions about public policies for the management of hospital quality, through an external evaluation, and also provide subsidies for the decision-making of managers and professionals working in public institutions, which seek to be certified by the Accreditation.

FINAL CONSIDERATIONS

In light of the statements provided by those interviewed, the Accreditation in public hospitals involves several advantages, such as similarities with private institutions, understood as a form of legitimation of the services quality and the promotion of a sense of pride and satisfaction among professionals. Based on this, we consider that the Accreditation has the potential to be consolidated as a system for quality management in the public health sector, with their purposes and clearly defined methods making it possible for government organizations to encourage the development of professional skills, cost management, increased structure, efficient management of care and appreciation among workers.

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Publication Dates

  • Publication in this collection
    May-Jun 2016

History

  • Received
    02 July 2015
  • Accepted
    28 Nov 2015
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