Challenges in the methodological path of building the Institutional Accreditation process for SUS ombudpersons

This paper aims to reflect on the theoretical and practical challenges in the methodological path of building the Institutional Accreditation process of the Unified Health System (SUS) ombudspersons, developing teaching materials, and the dynamics of fundamental interactions between the stakeholders involved. It discusses the trajectory of a working partnership between a team of researchers and a department of the Ministry of Health, which aims to theoretically and methodologically support the actions of the sector working on the principal participation and social control topics and, in particular, the ombudspersons, generating evidence for management decision-making. The authors present the challenges in partnership and the process and discuss from a methodological, reflective, and participatory viewpoint, presenting ideas and concepts that have evolved and govern the pedagogical materials prepared for the instrumentalization of the Institutional Accreditation process of SUS ombudspersons as a theoretical-practical framework. The authors conclude that adopting a challenging constructivist method is a healthy effort for self-improvement and guarantee of the affirmation of democratic values, effective in the constant search for the qualification of the actions of the ombudspersons, research activity, management practice, and services and public policies.


Introduction
Different types of bodies have been structured throughout the history of public administration and the corporate world to promote and facilitate the identification and handling of complaints, denouncements, suggestions, compliments, and other manifestations of users of services and systems and consumers of products/goods.
In particular, in public administration, ombudspersons transcend serving as a mere channel for voicing citizens' demands.They have been increasingly considered as management tools with crucial strategic potential in policymaking and the debate on how governments act to assist society in its well-being and living conditions lato sensu [1][2][3][4][5] .
Interesting studies and texts have been produced, debating possibilities and limitations of citizen interventions in public administration, varying institutional social control mechanisms, and representative, deliberative, and participatory democracy concepts 6-8 .This fact indicates that bodies, such as rights councils and ombudspersons, for example, have attracted the academy's attention and found, to some extent, technical and political conditions to be incorporated and sustainable into administrative structures in an ongoing process with constant challenges 9-11 .
In the field of health in Brazil, per what the Federal Constitution 12 and legislation establish, the consolidation of the Unified Health System (SUS) has institutionalized participation, social control, and dialogue levels between citizens and the managers responsible for the system, under penalty of not promoting its constant improvement and even compromising its functionality and performance [13][14][15][16][17] .It is a considerable challenge to affirm democratic values when considering varying historical obstacles addressed that have always existed in the country, marked by inequality, (social, economic, political) privileges of the ruling minorities, and the distorted or attacked idea of social participation.Thus, this article aims to report and reflect on the theoretical and practical challenges in the methodological path adopted in the Institutional Accreditation process of SUS ombudspersons resulting from this partnership and the teaching materials and dynamics of fundamental interactions for the work developed, broken down, and debated in the following sections.

First steps of the partnership
The partnership originally aimed to theoretically and methodologically support the sector's actions through preliminary research on the primary themes of participation and social control -and, in particular, ombudspersonsthus remedying a gap that had been observed in federal management in this field: the unprecedented research 'Baseline for Studies and Monitoring and Evaluation Actions in the Ombudspersons', which mapped and characterized 512 municipal ombudspersons registered by DOGES/SEGEP/MS and all 27 state ombudspersons offices part of the SUS; and generated evidence for decision-making to configure and consolidate a National System of SUS Ombudspersons (SNO-SUS), qualifying and enhancing it through decentralized implementation 13, 14 .
A Working Group (WG) was established within this initial study with members of the team of researchers and representatives of DOGES/SEGEP/MS, which explored many issues in several meetings, such as the following: What are ombudspersons and what other similar bodies/authorities/structures, governmental or not, have existed and exist in the country and the world?How can ombudspersons work, and what is their importance for public management?What relationships/ inputs can the experiences of the corporate world bring?What connections might they have with other bodies/systems?What is 'Innovation', its importance to public management, and how does it apply to ombudspersons?What are the challenges to be overcome, and the facilities could we build on in the relationship between academia and management that research would address?

Conceptual definition
With these issues in mind, concepts were debated to offer theoretical and practical subsidies for constructing an ombudsperson's typology 18 .The concern, therefore, focused on the ideas of functionality, action, and performance of the ombudspersons' problemsolving capacity while focusing on the search for smoother and more effective forms of interaction between the research team and the team of managers and technicians involved 18 .
The concepts of Participation, Information Management, and Resoluteness were considered fundamental and presided over the work in the WG's operation, generating products 18 that gave rise to another study entitled 'Survey of the Perception of Municipal and State SUS Ombudspersons on the Ombudspersons' Resoluteness', whose results of its application generated a Baseline for studies and Monitoring and Evaluation actions and a proposal of the 'SUS Ombudspersons Performance Index -IndoSUS'.Academic papers were also published 4,8 from this study on the ombudspersons' perception.
Challenging obstacles were identified in the search for quality assurance with excellence in the work developed by the ombudspersons and the SNO-SUS to be implemented.Given the country's continental diversity, we observed that the specificities and local and regional realities overly impacted each ombudsperson's performance.Therefore, they raised challenging questions for applying and using indices and indicators based on the resoluteness concept.
Anchoring IndoSUS in the concept of resoluteness expressed an excellent view of how ombudspersons should work.It was relevant when considering how to evaluate them for their practical performance capacities.If an authority such as ombudspersons do not perform their functions well or cannot resolve the problem raised by the SUS user, even if it is not directly responsible for the solution, they will not fulfill their role; therefore, a system composed of them will not be functionally adequate either.However, a change in the direction of the perspective can be a healthy sophistication regarding what is actually seen and what is intended to be seen so that what is seen is better seen and, therefore, better understood, evaluated, supported, and improved.
In the case of ombudspersons and the SNO-SUS, more is required to operate in a regulatory, bureaucratic way.Due to the very condition of bodies that establish direct contact between the SUS user and the system embodied in the people of the competent and responsible authorities -managers -ombudspersons are expected to contribute to the qualification of the actions and decisions taken toward constant improvement 7, 9 .
This fact implies the legitimation and credibilization of ombudspersons, management, information systems, system-end services, and the SUS.It has never been forgotten that it is fundamental for the practice of accountability that there are ways of measuring and evaluating the actions of bodies and authorities.The ombudspersons are neither excluded nor should they be exempted from this.The idea of the SNO-SUS was precisely intended to respond to this insofar as it could stimulate the exchange of enriching experiences between the ombudspersons.Therefore, we realized the possibility of experiencing another sense of understanding about how the ombudspersons could be analyzed and evaluated, transitioning from a heuristic conception marked by verticalization (performance ranking and ombudspersons' resoluteness) to a conception that prioritized the horizontality when addressing the ombudspersons, giving credit to their efforts to adapt and act before their local conditions.

Conceptual transition
Adopting a working method that had to be verticalized was a challenge from 2017 onwards.If the epistemic pattern before the idea of comparing ombudspersons expressed in the indices and performance indicators, it could generate discomfort among ombudspersons because eventual performance ratings of their ombudspersons were not positive; that risk was eliminated with a change of understanding.
Furthermore, with the idea that the reality of each ombudsperson is unique and, therefore, subjecting it to a comparison with the reality of others would be possible but unfair, we came to the understanding that each ombudsperson can (and must) exercise its self-evaluative autonomy within its conditions of operating and overcoming (or not) obstacles.In other words, self-assessment emerged as a logical and feasible proposal, articulating a notion of assessment devoid of punitive nature and merely accounting or measuring.Furthermore, external evaluation was crucial for achieving a vision about the ombudspersons securing the assessment of the quality of their already developed actions and potential.
This reflection, therefore, gave rise to stimulating challenges inherent in the transition to the notion of Institutional Accreditation of SUS ombudspersons based on the concepts of 'Quality Path' and 'Training in Action', drawing up a methodological path that necessarily involved the construction of theoretical-practical reflective and participatory processes and the elaboration of suitable teaching materials.From this perspective, the research team's role starts to assume an 'Accreditation Agency' nature under construction and responsible for conducting the entire process and for the accreditation itself, embodied in the assessment of a 'quality seal' to the ombudspersons that adhere voluntarily to the process.

Quality path in the accreditation
In the pragmatic world of public administration, particularly for health, the concept of 'quality' takes time and effort.It is a polysemic and complex concept, with meanings fundamentally established in a construction activity that is, therefore, artificial and arbitrary, however, extremely rich in applicable possibilities.
Whether adapting or using it immediately and directly, the concept of quality generally adopted is grounded in the most basic concept of the corporate world, briefly characterized by being based on meeting the needs of those interested in a given product or service.In the case of how the State is structured and works, actions, programs, and public policies are more than quantifiable; they are qualified in the face of collective demands and issues.The fulfillment of needs is measurable and qualifiable, therefore, to the extent, scope, depth, and meaning in which what is offered to the citizen is satisfactory or not to all the interests at stake.
As a result, one can conceptualize 'quality' as the robust path outlined and presented coherently and with goals established by the ombudspersons seeking the continuous improvement of the services provided to the population 19 .The course taken by ombudspersons will show all the more quality as the pillars for its implementation and sustainability are expressed in the respective action plan during the accreditation process, involving permanent negotiation, which is the main challenge for the ombudspersons, the team of researchers, and the managers involved in the construction of the process with the proposed Institutional Accreditation 19 .
If paths are understood as trails -but not trails, much less gauges -to be pursued/ achieved in the articulation of the idea of the trajectory of the ombudspersons' actions, and goals as horizons/settings to be achieved (or not) in a time self-determined by the ombudspersons, an understanding of what is proposed as a 'Quality Path' of an ombudspersons is reached.It will be intelligible, identifiable, and assessable by how and to the extent that the action plan has the power to express backdrops in which the actions already developed and planned are discussed and the types of involvement and engagement of stakeholders and arenas considered strategic partners toward achieving the stated objectives 19 .
Thus, we identified the need to organize a theoretical-practical framework that entangles the stakeholders involved in the process -a team of researchers/'Accreditation Agency', MoH managers/technicians, external evaluators, ombudspersons' technical teams, and their strategic partners.Understanding this as one of the methodological challenges of the entire process, we found that it was necessary to establish a nondogmatic guideline, something quite challenging, which is discussed in the next section of this paper.

Dynamics between elements and in the elaboration of teaching materials
In general, when thinking about training people, we should establish what one intends to develop, considering the (material and subjective) conditions of all the stakeholders and arenas involved in and through which the reflections will be made and the essence and purpose of the training process.What and how, for what, and for whom to train?Who forms and who is formed?These were, are still, and will continue to be fundamental issues in the process, given the need to adopt a theoreticalconceptual framework for the work, and also the planning and implementation of a training course for external evaluators, attentive to the principles of Continuing Health Education (CHE): It is not a process of unilateral transfer of knowledge, but of collective, organic learning, experienced by all those involved 20 .
Therefore, we had to produce texts that substantiate all the relevant reflections and simultaneously subsidize the elaboration of new reflections, keeping alive the flame of transforming experimentality without losing sight of the relevant need for a structuring beacon without being inflexible.

Inspiring Teaching Artifacts
Four texts were prepared.The first arose from a demand on how the proper functioning of ombudspersons could be debated, which resulted in the elaboration of a 'Document of Good Practices in SUS Ombudspersons' 21 .Although there were already published materials on the subject, we started from the premise that materials used by different organizations recognized/known as 'good practices' could be debated and improved from the work and experience of managers and ombudspersons and in the daily feedback of users 21, 22 .
The 'good practices' adopted are defined as a set of existing innovative techniques or mechanisms employed to achieve a better result in work processes 21, 22 .Such techniques can be changeable, as they are based on everyday work experiences, so a good practice is inherently an experience endowed with liveliness.
This document worked with a tripartite dimension: citizen participation through the reception of manifestations, improved policies, management, actions, and health services that can enhance the expansion and strengthening of social control; the daily work of the SUS ombudspersons through internal and external positive actions, involving improved processes and innovation or transformation of public management; and the context of the ombudspersons' relationship with the management of the health system, guided by collaborative actions that contribute to improved service provision, and better management 21 .
Therefore, unlike traditional prescriptive texts, the document aimed to present and expand the discussion of expressed good practices in SUS ombudspersons between federal management and ombudspersons across the country, aligned with the idea of consolidating the SNO-SUS.While not a teaching material in the strict sense, it meant an essential subsidy for thinking about the issues to be addressed throughout the Institutional Accreditation process, with its reflective core converging with the issues that permeated the other texts produced.
Effectively focused on the work of Institutional Accreditation with the ombudspersons and in the context of the need for pedagogical materials to work with the professionals who would conduct the external evaluation, three other texts were prepared: the 'Manual for Institutional Accreditation of SUS Ombudspersons' and the 'Quality Reference Document' (QR), included in the publication 'Institutional accreditation of SUS ombudspersons in Brazil: basic documents' 19 , and the 'Profile of the External Assessment Team on Institutional Accreditation of SUS Ombudspersons' 23 .
Despite its name, the 'Manual' does not aim to dictate procedures dogmatically.It is a document of communication for action with bases established in the organization of the quality policy and the flows of Institutional Accreditation.It helps the ombudspersons, with the accrediting entity -that is, the research team -justify their choice and adherence to the accreditation process, the self-assessment of SUS ombudspersons practices, and the involvement in the practices in defense of rights and to improve health actions and services in ombudspersons and the SUS 19 .
The 'Manual' addresses the definition, objectives, and fields of action of the Institutional Accreditation of SUS Ombudspersons.It proposes a National System of Institutional Accreditation of SUS Ombudspersons (SNAIO-SUS), discusses general accreditation procedures, and, finally, indicates guidelines on the means of verification during external evaluation.The document also presents a glossary of essential terms to be understood in the context of the accreditation process, emphasizing that such words have a generalized definition, as they should be explained in each singularity experienced by each ombudspersons 19 .
In a dialogic movement twinned with the 'Manual', the QR proposes itself not as a gauge indicating how the ombudspersons should act but rather as a mainstay for the autonomous construction of their paths.In this sense, intellectually honest and profound reflection on the part of all those involved in their work processes is essential to make this happen.In this spirit, it was elaborated from productive interactions developed in workshops held in 2016 with a group of state and municipal ombudspersons and representatives of the Ministry of Health and expressed an argumentative set of ideas that seek to consider the daily work process in the ombudspersons' offices and the relationships with different partner interlocutors required for its accomplishment.
In practical terms, the conception of quality in the path of ombudspersons expressed in the QR occurs through the organization in four dimensions that involve the work in the ombudspersons' offices: Infrastructure, Management, Work Processes, and Results.Furthermore, they cover 14 sub-dimensions containing arguments that express their central ideas, which, in turn, unfold into different benchmark standards, totaling 68 19 .
Thus, the theoretical and practical challenges to the ombudspersons must constantly be (re)constructed and resignified from the relationship between them and the QR.Therefore, the desired effect made possible by the relational dynamics with the QR intends to stimulate and implement a Self-Assessment Culture in the ombudspersons, preparing the ground for the External Assessment, another stage of the Institutional Accreditation process.
The interaction of the participants in the process of elaborating the QR and the 'Manual' led to the emergence of theoretical, practical, political, and ethical issues, not only in what applies to the work of the ombudspersons but also in the daily work of management and the research team itself.Diversifying stakeholders meant a collective challenge of building consensus and managing the inevitable disagreements.It was confirmed that the difference is creative in the inter/activity and inter/action with the figure of the 'other'.Moreover, the estrangement-familiarization game is affirmed as an intrinsic component of the entire process, and is very much visible in the External Assessment, when the ombudspersons meet with a team that will conduct an 'evaluation' -that is, give an endorsement 24 .As a result, the importance of the performance of external evaluators was revealed in its magnitude and relevance, and issues arose regarding the planning and implementation of the training course.

Ongoing training
Simultaneously with the course planning, it was necessary to stipulate the notions of 'evaluation', 'external evaluation', and 'external evaluators' underpinning the entire process.To this end, a document entitled 'Profile of the External Assessment Team in the Institutional Accreditation of SUS Ombudspersons' 23 was prepared, using the collective construction of reflections in the expression of inter-relational dynamics between research teams and management again.
With a more specific objective of debating the concept of an External Assessment Team (EAT), the 'Profile' reflects the ambition already indicated in the 'Manual' of the formation of SNAIO-SUS, operated by an 'Accrediting Agency' and based on constant learning, which implies a periodic validation.Fundamental characteristics referring to previous knowledge, skills to be developed, and relational attitudes of the professionals responsible for the external evaluation of the ombudspersons 23 were explained.
The practical application of the 'Profile' constructed through a participatory method was designed to occur as a tool for the organizational learning method of the course offered in 2018 for professionals who composed a bank of external evaluators at the end of the course and a basis for the continuing recruitment of new external evaluators.As the primary concern was with the design of an EAT, and since the Institutional Accreditation process involves the concept of participation, the conception that the work of external evaluators is grounded in the collective sense was inescapable.
This fact brought, as a challenge, the proposal to work on the idea that individualities should not be denied, under penalty of losing the richness of intersubjectivity, while affirming the fundamental exercise of pacts, negotiations, agreements, and consensus.The EAT is designed to be composed of individualities whose multiplicity becomes rich as differences are understood and operated as aggregators and constructive, even if passions, idiosyncrasies, and divergent opinions are not necessarily extinguished, which is also the case for the research and management team and the ombudspersons teams participating in the process, which makes the task of carrying it forward in a balanced way challenging.

Final considerations
Indeed, the robust methodological challenges present in the Institutional Accreditation process are generalized to all the actors involved.They are constant, re-adjustable, and renewable, with each ombudsperson's experience adhered to because of the theoreticalphilosophical disposition underlying the proposal: a constant learning process.
The Institutional Accreditation of SUS ombudspersons consists of recognizing the social competence of the accredited entities given their consistent capacity to conduct their actions to build a relational dynamic of trust with stakeholders considered strategic partners through cooperation and cooperation, and shared responsibility.The commitment assumed is with quality from an internal and external viewpoint to its work, which is that accreditation is 'a collective quality management through which an institution, entity, agency, or company seeks to reflect on acting in its work process to achieve social recognition' 19 .
The expected observable effects of an accreditation process are as follows: a) the continuous improvement of quality, not only of the actions of the ombudspersons, but also of the levels of management of the system, services, and the SUS -to give sustainability to this posture is indeed the great challenge -; b) the affirmation and maintenance of credibility in the performance of the ombudspersons' actions, building where there is none and consolidating where there is already legitimation and legitimacy for these entities -which is another challenge, more political than technical -; c) valorization of collaborative action among all the social stakeholders involved, corroborating the promotion of a constructivist and participatory nature in intra-and intergovernmental, and non-governmental relationships -also of a political nature, which is a crucial challenge insofar as the proposal intends to show that the accredited status conferred on the adherent ombudspersons is the expression of public faith endorsed by different social stakeholders 19 .
Again, the process works with the idea of seasonality; and, for the ombudspersons, this means that a cyclical temporality of request for reactivation of accreditation must be included in the action plan, representing a fine calculation of the possibilities inherent to the actions of the ombudspersons when following their Quality Paths.The global context of the COVID-19 pandemic, which hinders face-to-face contact essential for the External Assessment, is undoubtedly another challenge for all the stakeholders involved.
The successive stages or steps of the proposed Institutional Accreditation process are linear, at least on a theoretical level and for the visualization and understanding of the actions of each responsible participant in the process.It starts with the Adherence step or stage, proceeds to Self-Assessment, External Assessment, and culminates with Accreditation, with one only starting with the end of the former, without a predetermined temporality.In practice, however, the temporality of each step or stage can be affected by the conditions arising from interactions with the ombudspersons and the respective local injunctions, which affects the theoreticalpractical guidelines expressed in the teaching materials, providing the opportunity for feedback and renewal.
Thus, we can understand the ombudspersons' work in spatial and temporal dimensions that consider structural, technical, and political factors throughout their past, current, and future history in a balanced way, mitigating biases.
Precisely when seeking to alleviate biases, with the awareness that they will never cease to be present in any human activity and, even more, with the understanding that they underlie the realities with which we deal in daily life, is that the External Assessment emerges as the stage after the Self-Assessment.All the work developed in elaborating teaching artifacts and other external Assessment Training course materials is felt in its fullness.

From
convergent opportunities, in 2013, a partnership was signed between a team of researchers from the Oswaldo Cruz Foundation and the then newly created Department of the General Ombudsperson of the SUS of the Secretariat for Strategic and Participatory Management of the Ministry of Health (DOGES/SEGEP/MS), currently Ombudsperson-General of the Unified Health System of the Department of Integrity of the Ministry of Health (OuvSUS/DINTEG/MS).