Institutional Accreditation of SUS Ombudspersons: An analysis of the initial external evaluation experiences

Based on the Qualification course of External Evaluators for the Accreditation process in the Unified Health System (SUS), held in 2018, this paper aims to discuss the challenges to the training process of these evaluators from a perspective of participatory evaluation to contribute to the improvement of external evaluation and self-evaluation devices. To this end, 33 documents produced with the practice of these devices were analyzed within the project. In external evaluation, the main challenge is to ‘look at the other’. This specific type of perspective requires the External Evaluation Team’s mastery over the previous knowledge, skills, and attitudes necessary for the work to capture knowledge, intentions, and relationships expressed in the statements of the subjects. In self-evaluation, the main challenge is ‘looking at oneself’. Taking oneself as an object of knowledge and field of transformation requires specific ways of doing to gain quality in work processes. Building a culture of evaluation in which the information produced supports decision-making is a challenge for the ombudspersons, which can be overcome with the Quality Benchmark of the Ombudsperson Services of the SUS.


Introduction
The Institutional Accreditation of Ombudspersons of the Unified Health System (SUS) is a project that was born from the realization that it would be innovative and productive for public health management to approach and evaluate the Ombudsperson work process from the production of reflections on the daily life of their practices, to empower them and help them perceive themselves as important management tools 1 .
The construction of this project is a partnership between researchers from the Department of Social Sciences of the Sergio Arouca National School of Public Health of the Oswaldo Cruz Foundation (ENSP/FIOCRUZ) and the General Ombudsperson of the Unified Health System (OuvSUS) of the Integrity Department of the Ministry of Health.
Accreditation will reach the proposed objectives only when facing the challenge of creating an evaluation culture.The information produced in this process supports the decision-making by the different stakeholders, generating changes, which is only possible if this judgment can be critical and induce training and learning 2 .
The model under construction for the Institutional Accreditation of SUS Ombudspersons comprises two evaluative devices.Self-evaluation carried out at the institutional level by professionals who develop the practice in the Ombudsperson's office and by strategic stakeholders who, given the mediation and interactivity nature of this work, affect or are affected by it.In external evaluation, a team analyzes the process previously built by the ombudspersons' offices to identify compliance and consistency in the quality path built for these ombudspersons, creating subsidies for decision-making and improving the quality of care.
In both devices, it is necessary to discuss what to evaluate, how, and which stakeholders to incorporate in this process, considering that the ombudsperson's work is not an end in itself.
It is relational, in which it is built individually or collectively from the composition of technologies and tools -hard, soft-hard, and soft -that allow different professionals to agree on their work process and care production 3 .
The External Evaluation Team (EET) must have toolboxes, knowledge, and relationships expressed in statements and perceive the intentions of these actions 3

Training in action (or navigating is necessary): the bases of its construction
In the course and the very Institutional Accreditation process, training is understood as an ongoing qualifying process, in a state of incompleteness, and, therefore, constantly (re)updating through the experience lived by professionals in their different learning stages mediated by the narratives of teachers/learning facilitators.The dynamics of construction, systematization, and organization of the reflections and all the work by the participants are recorded in a device entitled 'Logbook' 4 .
The qualification was structured considering that the course's target audience, higher education health professionals working in Ombudsperson offices, had previous mastery of some content on evaluation, public policies, management, teamwork, participation, and social control.
The construction of the pedagogical activities aimed to analyze in-depth important concepts for accomplishing the external evaluation.In this sense, it was intended to hold a manageable amount of lectures on each concept or theory but, based on the experiences brought by professionals, the available bibliography, and the group and plenary work, to discuss the concepts worked.Therefore, it aimed to produce elements that would allow the evaluators to capture beyond what was apparent, perceiving the intentions, values, contradictions, and disputes in the production of the making underlying the ombudspersons' work and their implications for health care 5 .
Thus, the knowledge built for the evaluation would be based on experience, which, as Bondía 6 teaches, "is everything that happens, comes to us, and happens to us".Therefore, knowledge must be experienced and reflective, avoiding the incessant search for information, excess opinions, timeless reflections, and excessive work seen by the author as elements that hinder its construction.He says: The subject of the experience is affected by it, who generates and is impacted by affections, leaves some traces, and is exposed, with all the risks and vulnerability that this exposure may bring 6 .
The course curriculum layout was based on the notion of 'training in action' aligned with this perspective, in which the curriculum and the course's development are organically conceived, valuing the experience of the subjects involved to generate reflective autonomy.They are encouraged and debated as a theoretical reference and reflective basis for students' pre-existing knowledge 4 .
These conceptions are synthesized in the pedagogical material entitled 'Navigation Chart' 4 , prepared by the team of researchers who developed the project.The choice of this title reflects the conception that the horizon of knowledge is in constant (re) construction and, although it is subject to currents and tides, storms and calms, fluidity and obstacles, it is subject to mapping and (re)discovery providing security throughout the trajectories.
The course was organized into three learning units dedicated to each of the phases that make up the external evaluation (preparation, development of the external evaluation, and systematization of the external evaluation process).Its realization aims to account for the following precepts: i) Understanding the guidelines and objectives of Accreditation and external evaluation of SUS ombudspersons; ii) Planning and scheduling the external evaluation; iii) Developing an external evaluation process in the SUS ombudspersons practice; iv) Preparing a summary of the practice of external evaluation for collective quality management of SUS Ombudspersons 4 .
Each learning unit involved face-to-face moments and distance meetings, facilitated through a community called Virtual Learning Environment (VLE), constituting the learning communities made available through the Moodle platform by the ENSP/FIOCRUZ Distance Learning (DL) department.
From this perspective, training is conceived from a technical-political-ethical viewpoint, which values the construction of inquiries and questions about thinking, doing, what one thinks, what one does, and what one thinks is doing or can be done.Aligned with this spirit, the course proposal is an ongoing training process and not limited to its first offer.
It was initially agreed with the Ministry of Health to carry out an external evaluation of ten ombudspersons, distributed from pre-established criteria, to consider the variety of SUS ombudspersons in the country: regional diversity, municipalities of different population sizes, ombudspersons belonging to (state and municipal) administrative spheres and different complexity levels (central and hospital).For operational reasons, seven evaluations were carried out during the course and two in 2020 after completion.Accreditation is underway in 24 Ombudsperson offices in the current project's phase, including some Ombudspersons that participated in the initial phase.
The teams consisted of two to three professionals in training to carry out the external evaluations.This number varied per the population size of the municipalities where the ombudspersons were located and, therefore, the complexity of their respective networks.Learning facilitators who led their adherence process and accompanied the EET mediated the relationship with the Ombudsperson.Moreover, the experience of conducting an external evaluation by the professionals was systematized in the external evaluation report.

Flow and stakeholders involved in the Accreditation process: understanding the place of external evaluation
The Institutional Accreditation System is built on self-evaluation and external evaluation devices, which jointly aim to understand how actions to improve health services are conducted/enhanced within the SUS Ombudsperson.The consistency of the discursive practices produced by these devices provides the basis for decision-making by the Accreditation Committee and its subsequent seal to the path of quality of services built by the Ombudsperson.
These devices are operationalized at different stages of the Accreditation within a flow.The elements built in one phase serve as a basis for reflection and further in-depth analysis of the subsequent phase.It begins with the agreement on the Accreditation objectives between the project coordination and the Ombudsperson to be accredited.The publication of an ordinance by the institution with the composition and attributions of the Quality Management Team (QMT), a working group composed of internal and external stakeholders chosen by the Ombudsperson in its partnerships with other sectors of the service or civil society, materializes the adherence of the Ombudsperson to Institutional Accreditation and expresses the institution's commitment and involvement with this process.
This team is responsible for coordinating the self-evaluation process and preparing the selfevaluation report and action plan, which should express a reflection of the professionals on their daily work.In other words, it is an analysis in which the Ombudsperson subject must talk about himself/herself, from a critical perspective of the various professionals working in this space about their work process and the relationships built by the Ombudsperson with other services/stakeholders, to facilitate the construction of agreements and actions that will allow addressing problems toward achieving quality.Furthermore, it is conducted in dialogue with the Quality Benchmark (QB) 7 produced for Accreditation in SUS Ombudspersons, expressed in four dimensions (infrastructure, management, work process, and results) which, in turn, unfold into sub-dimensions, arguments, and reference patterns.
Once completed, this report is submitted to the Accreditation Project Coordination and then distributed to the EET, a working group mobilized by the accrediting entity.The report will be used as a subsidy for elaborating field roadmaps.At this stage, it is necessary to identify the problems to be better understood and investigated, schedule the visit period, and define research techniques and tools (interview and focus group scripts) to be used with the different stakeholders.
The external evaluation visit allows for on-site analysis, the perception of how much the quality path designed in the Ombudsperson's action plan described in the self-evaluation report was in compliance with the reference standards described in the QR and showed consistency, that is, chaining of coherent and powerful discursive practices to improve the quality of the SUS health Ombudsperson services 7 .
These impressions are systematized in the external evaluation report.Finally, based on this report, the Accreditation Committee decides and approves the process developed by the Ombudsperson, closing the cycle.

Challenges for consolidating the Institutional Accreditation System
Thirty-three documents were selected from the nine Accreditation experiments already conducted within the Project to reflect on the challenges of these initial external evaluation experiences.Such documents consist of nine self-evaluation reports, nine external evaluation reports; seven 'Cross-Analysis Activities' -exercises of cross-reading and self-reflection on the external evaluation reports, prepared by the coordination team and performed by the evaluators in training; and eight tools of 'Reflection on the Experiences of External Evaluation', answered by professionals in training, who participated in two different experiments.
Although the analysis focused on external evaluation reports, given the interconnected nature of the devices, the inclusion of self-evaluation reports produced by the Ombudspersons was essential to understand how much the production of the self-evaluation impacts EET's work.
Such documents reflect the possibility of product qualification of the two primary Institutional Accreditation devices.The indepth quality of these reports traverses, organically, the reflection of the entire work process that constitutes them.
The analysis of these documents revealed two macro-challenges in the self-evaluation and external evaluation devices: i) the Quality Management Team and the challenge of 'looking at oneself'; and ii) the EET and the challenge of 'looking at the other'.Both challenges unfold into a set of specific questions.Now, if the self-evaluation work consists of 'looking at oneself', the question is: how does one build internal coherence between the discourses produced on everyday practices experienced within the Ombudsperson?How does one sort out these elements logically to allow the other to be 'able to see' and understand such a reality through what is presented to him/her by another team without him/ her having lived such an experience?What analysis tools does one use in this case?
In turn, if the work of external evaluation consists of 'looking at the other', the question arises: How does one capture what this other produces?How does one perceive the potentialities and weaknesses in the existing interactions where the Ombudsperson practices are forged?What will be observed, with which stakeholders, through which tools?To what extent does the self-evaluation report prepared by the Ombudspersons capture such practices?What other materials are required for the EET to understand the Ombudspersons' work routine and the social and political context in which it operates?How does one build a report to support the Accreditation Committee's decision?How does one create consensus and compositions from different perspectives as a team?
Next, we will reflect on these challenges and their specificities arising from the Institutional Accreditation experiments within the Qualification Course for External Evaluators to improve the training processes.

The Quality Management Team and the challenge of 'looking at oneself'
The guiding principle of the QMT is 'looking at oneself', that is, taking the work performed by the Ombudspersons, in its multiple social relationships, as an object of study and field of action to transform their values and practices.In this conception, applying on oneself is a primary condition for taking a political position 8 .
The QMT is responsible for giving consistency to this concern by constructing the self-evaluation method.Some of its main attributions are identifying the problems that demand actions to overcome them; developing a sustainable action plan; setting in motion the quality path proposed in the plan to overcome the challenges, problems, and critical nodes identified; and defining the elements for monitoring this process.
The construction of this method, whose practice is devoted to 'looking at oneself', is one of the main challenges Ombudspersons in the self-evaluation process.Taking oneself as an object of knowledge does not designate a diffuse concern.It represents specific forms of exercise and practices that are reflected, developed, and perfected to materialize selfknowledge, which is necessary to assume public responsibilities, actively participate as an instrument of public management, and contribute to SUS health policies 8 .
The QR proposed by the Project Coordination aims to offer standards and arguments that allow the Ombudsperson to see itself from a logical framework, identifying its weaknesses and potential.Mediated by the QR, the ombudspersons can carry out the educational debate of their daily work (what one knows what to do in the face of specific realities), aiming at learning at work through the appreciation of local experiences 7 .
Such practices are interested in constantly questioning the attitudes that should be taken in each favorable and unfavorable circumstance.It is, therefore: i) administrative control to evaluate an activity performed, reactivate its principles and correct its future application; ii) the examination of the daily journey; iii) verification of work compliance and consistency; iv) mapping the rules of conduct that allow achieving the proposed objectives, using the most appropriate means; and v) the watchful attitude towards oneself 8 .
Associated with this difficulty in building the self-evaluation method is another relevant challenge for the device's success: the construction of internal cohesion among QMT participants.The analysis of documents produced in the initial experiences of Institutional Accreditation showed that the main weaknesses observed were related to the lack of shared responsibility among the team members; the participation of sectors unfamiliar with the Ombudspersons' work routine; and the lack of multiple perspectives for the composition of the report.
As a consequence of this lack of internal cohesion, the main weaknesses identified in the self-evaluation report were inconsistent information, which did not demonstrate the reality of the Ombudspersons' office; reports focused on a non-diversified and non-participatory view of the QMT and self-evaluation process; and lack of an effective and verifiable action plan.
A systematic and permanent evaluation culture in the country's health services is necessary for the Ombudspersons' understanding of how much the organization of their work process affects their daily work and decisionmaking in other spaces or management levels.In this sense, the QR can become an essential ally in building this evaluation culture.
However, this is insufficient.These reflections should transcend the Ombudspersons' wall and involve other sectors/services and the institution's management.The involvement of these stakeholders/services will allow the QMT to set the pillars for the construction of the necessary agreements so that the quality path to be followed reflects improving services and responds to the manifestations of users/ citizens.The QR encourages social stakeholders to assume the choices made collectively.Group decisions and agreements between the several social stakeholders in the dialogue and interaction process cover the object of self-evaluation, how one wants to assess the understanding of contexts, knowledge, norms, procedures, and actions and reactions, which imprint results 7(13-14) .
The democratic management values the construction of negotiated communication channels and shared responsibility in the daily decisions of the SUS Ombudsperson, aiming at quality as a negotiating challenge for social production in health.
The work process performed by the QMT is, therefore, a learning relationship at work that involves deconstruction-reconstructionstructuring and the discovery of new collective strengths between partner stakeholders and other sectors of the service or civil society.
Such a political exercise is anchored in the interest of a continuous improvement of the quality of the work carried out by the SUS ombudspersons: an ongoing public action construction.It is noteworthy that the principle of 'looking at oneself' objective has a group dimension: it applies to oneself, to take care of others; in this case, promoting the practice of democracy, defending human rights, mediating conflicts, enhancing the ability to listen and recognize people as subjects of rights 8, 9 .This is, therefore, one of the most critical points of this attitude consecrated to the 'looking at oneself': a social practice.The challenge of institutionalizing a culture of self-evaluation brings with it the concern of constantly improving the health services the SUS provides to the population and strengthening the quality management of work processes.

The External Evaluation Team and the challenge of 'looking at the other'
The leading attribution of the EET is to carry out a field visit to the SUS Ombudspersons involved with Institutional Accreditation, aiming to analyze the practice of quality in its actions, having as a reference the perceptions of the subjects and the dimensions of the work addressed in terms of infrastructure, and the work, management, and results' process.It is about interpreting and translating the work of the Ombudspersons and their institutional culture 10 .
The external evaluation mainly aims to verify the compliance requirements met in the Ombudspersons' performance structure and consistency in carrying out actions based on the quality path, evaluating the sustainability of implementing the propositions defined in the self-evaluation report and the quality action plan.
In this sense, EET's practice is not an 'end in itself'.It underlies the Accreditation process and one of its main features is intermediating between self-evaluation and Accreditation 10 .
The principle on which the work of external evaluation is guided is 'looking at the other', which means realizing, in the interactions where the Ombudspersons' practices are forged, how the identified weaknesses are faced and the potentialities valued, improving the Ombudspersons' services to citizens.This EET perspective dedicated to the Ombudspersons is mediated by the benchmarks that forge the Institutional Accreditation System of SUS Ombudspersons, specifically, the concept of quality.
The first practical challenge to EET's work arises from the postulate of 'looking at the other': preparing the field visit.The preparation of the field visits was organized by the teams around three main aspects based on the analysis of documents of the initial Accreditation experiences, as follows: 1) Synthesis of the Self-Evaluation Report -analysis of the material sent by the Ombudsperson, focusing on the visualization of its work processes and the identification of the quality path built; 2) Documentary Survey -search for documents, data, and information on official websites, aiming to consolidate the understanding of the Ombudspersons' work routine and their political-social context; 3) Delimitation of Objectives and Elaboration of Roadmaps -definition of what will be observed, which stakeholders will be activated, and which investigation techniques will be mobilized.
The success of the external evaluation is linked to the EET's investment in these three aspects.The production of consistent visit itineraries that identify statements from different stakeholders, which express the feasibility of implementing the path designed by the Ombudspersons in their action plan and disputes related to the Quality Path, depends on the articulation between these stages.
In external evaluation, as in social research, you only find what you are looking for.One needs to know the questions to have the answers.Consequently, the first requirement for the external evaluation is thorough training in the theoretical benchmarks of Institutional Accreditation, which allows the EET to know 'what' and 'how' to observe.It is necessary to know precisely what one wants, which depends entirely on the precise delimitation of the objectives that guide the field trip 11 .
The more lucidity the EET has on the issues that it intends to delve into in the field visit, the more the Team will be able to capture the discourses to build an influential report.Another vital challenge emerges for the EET linked to the concern of preparing for the visit: to ensure subsidies that facilitate the Accreditation Committee's decision-making.
The feasibility of this challenge is related to the consolidation of the external evaluation report, produced from the triangulation between i) the self-evaluation report; ii) the information gathered during the field visit; iii) the reference standards in the SUS Ombudspersons' QR.
The importance of solid theoretical foundations is revealed when EET returns from the field and is responsible for producing this report on the Ombudspersons visited.The decisive battle for constructing an influential report is not fought in the field but when returning from the field, which can only be achieved with systematic training in the prior knowledge, competencies, and relational attitudes required for EET's work 11 .
The theoretical investment that underlies such analysis is focused on evaluation and innovation; education and health; public management and administration; participation and social control; social research; SUS and its ombudspersons; quality policy of the Institutional Accreditation of SUS Ombudspersons; the SUS Ombudspersons' QR; goals defined by the ombudspersons involved with the Accreditation process in the self-evaluation report; and the external evaluation objectives.An in-depth analysis of these themes is essential for completing the external evaluation report 10 .
The mastery and articulation of these references ensure EET's interactions with the Ombudsperson services to perceive the compliance and consistency of the quality path, translating such practices into a report that supports the decision of the Accreditation Committee.
The EET should share decisions and responsibilities without losing the group perspective of work, as a process developed in a team, to achieve these goals.This relational work is materialized through agreements between different stakeholders, focusing on constructing compositions between perspectives, subjectivities, and competencies.
Health as a complex social practice can only be understood from a set of interdisciplinary knowledge, which, when articulated, enable the evaluation team to mobilize them to understand the work of a given Ombudsperson 10 .

Final considerations
The issues addressed in this paper allow us to point out that the QR was robust to set in motion the self-evaluation and external evaluation devices designed from a participatory perspective.The dimensions and standards presented encourage the participants of the self-evaluation and external evaluation to reflect on the work process developed by the ombudspersons, identifying the challenging issues and their strengths and weaknesses so that the desired quality path is pursued.
From this perspective, quality is seen as an ongoing construction process with no arrival point.New issues appear when reaching specific proposed objectives, which places the need to carry out constant adjustments/ changes in practice through a permanent dialogue with society.
This gives the Ombudsperson services the prospect that the evaluation is no longer a specific moment and becomes routine.In this sense, the huge challenge is to face the conditions for its sustainability before the health care needs and emergencies, in which everything is overdue.The size of these challenges depends on several issues, for example, the political and institutional conditions, the level of complexity of the health system where the Ombudsperson is located, and the decisionmaking autonomy level.
In the case of external evaluation, it must be able to capture this path and carry out analyses that produce information that strengthens the debate and learning about the ombudspersons' work processes so that the evaluation legitimizes these processes, thus improving the SUS.In the same way, the variety of experiences in the daily work in the ombudspersons' offices brings to the continuing training of external evaluators the challenge of understanding the specificities of the processes within the scope of the Ombudspersons and, at the same time, having a QR.