DESCREDENCIAMIENTO DE LA CERTIFICACIÓN POR ACREDITACIÓN HOSPITALARIA: PERCEPCIONES DE LOS PROFISSIONALES

Estudio descriptivo-exploratorio, cualitativo, con objetivo analizar las percepciones de profesionales sobre la inhabilitacion de la certificacion por Acreditacion Hospitalaria. Fue seleccionado un hospital que perdio el titulo de Acreditacion con Excelencia. Con la asistencia de 23 profesionales que trabajan en cuidado o la gestion do hospital, en mayo de 2014, respondieron a una entrevista semi-estructurada, grabada, guiado por la pregunta: "Hablame del descredenciamiento de certificacion de este hospital". La transcripcion tematica y analisis de contenido de entrevistas, se incautaron tres categorias: Inhabilitacion de la Certificacion por Acreditacion: motivos mencionados por los trabajadores; sentimientos negativos relacionados con el descredito de la certificacion; descalificacion de la certificacion: razon insuficiente para abandonar los principios de Acreditacion. Se concluyo que la perdida de certificacion de Acreditacion causo profundo sentimiento de pesar entre los trabajadores. Sin embargo, por favorecer la calidad de atencion, los participantes senalaron principios esenciales de Acreditacion y algunas acciones implementadas que permanecen en el servicio.


INTRODUCTION
2] Years later, through service management, the health institutions became increasingly concerned with the health care delivery, maintenance and assessment. 1 Quality assessment in health evolves according to the needs of the organizations, and mainly of their users. 2In that context, the health institutions, through the Accreditation, which correspond to a quality management system for systematic, reserved and periodical assessment, based on previously defined quality standards, [3][4] has gained visibility around the world.
In the Brazilian as well as the international sphere, Accreditation comes with important benefits for the promotion of health care quality and security.][7] In Brazil, the participation of health institution in the Accreditation process is still voluntarily and not characterized as a responsibility of the State. 8hus, the institutions concerned may request a national and/or international Accreditation through non-governmental or non-profit organizations. Under international influence, the ONA maintains the logic and method of the Accreditation based on the rationalization of work; continuous assessment followed by planning in favor of improvement; cost reduction and continuing education of the entire organization. 3,9In that sense, the assessment by the Brazilian Accreditation may or may not produce a quality certification, which in this case is established at three levels (Accredited, Fully Accredited and Accredited with Excellence), through increasing requirements for the health service assessed to comply with. 3hese Accreditation certification levels mediated by ONA should be continuously revalidated for the process to reach its essential objective, 3 which is continuous improvement. 5,9The validity of the certification at each level is one, two and three years and these periods are established in line with the increasing order of the certification levels mentioned. 3,5Thus, there are different reasons not to revalidate the quality seal, commonly related to the continuing non-compliances explicitly described in the Brazilian Accreditation Manual for Health Organizations. 3 Despite the benefits of the Accreditation and despite the fact that research on the theme has increased in the Brazilian and international context of scientific publications, at least in some important databases, no publications are found that are focused on the disqualification of Accreditation certificates.That was the result of searches undertaken in September 2014 in the online databases of the Biblioteca Virtual de Saúde (BVS); Scientific Electronic Library Online (SciELO); Literatura Latino-Americana em Ciências da Saúde (LILACS); National Library of Medicine (Pubmed); Base de Dados em Enfermagem (BDENF) for the period from 2004 till 2014, using only the descriptor "Hospital Accreditation" and its equivalent in Portuguese.
Based on the assertion above and on the fact that Accreditation entails important benefits for quality in the health area, this strengthens the need for studies on the research problem presented because knowledge on events related to the disqualification of the certification by the hospital accreditation, such as its causes and consequences, can help the managers of health institutions to maintain the process and to clarify doubts unexplored thus far by those aiming to gain certification.
In view of the above, this study departs from the following question: How do the professionals perceive the disqualification of the certification at the hospital where they work?And to answer that question, the objective in this research is to analyze the perceptions of professionals on the disqualification of the hospital accreditation.

METHOD
Descriptive and exploratory study with a qualitative approach, undertaken at a general hospital in the South of Brazil.The place of study was selected through the following criteria: being a general hospital, located in the State of Paraná; and whose certificate of Accreditation (independently of its level) was canceled recently, according to the ONA website of canceled certifications.During a consultation in the light of these criteria in November 2013, a philanthropic institution was selected with an operating capacity of 142 beds and; in the same year, lost the hospital certification Accredited with Excellence.
As a criterion for the professional's participation, called Quality Manager, it was established that the professional should have participated in the implementation and maintenance of the Accreditation process.The remaining professionals who participated in the research could relate to any hospital activity and/or sector, provided that they had participated at least in the most recent quality audit by the accrediting institution.Respecting this criterion, the participants were chosen upon the Quality Manager's indication, departing from the premise that he was familiar with who had participated more actively in the certification process.In addition, in cooperation with that professional, efforts were made to include professionals with different educational backgrounds and/or functions.
The data collection, which took place in May 2014, was prescheduled through the researcher's personal contact with the participants, and the interviews were held at their place of work in a private room.Before the data collection, the researcher ratified the study objective with the participant and each of them signed a copy of the Free and Informed Consent Form (FICF), together with the responsible for the research.The participant received one signed copy and the researcher the other copy.
After the clarification of possible doubts and the signing of the FICF, a form was applied with questions on the demographic and professional characteristics of the participants, followed by the interviews, which were recorded and based on the following question: Tell me about the disqualification of this hospital's certification by the Accreditation.
The number of interviews was established when the study objective was reached, represented by the successive repetition of the content the participants provided.Next, the entire material was fully transcribe, followed by the data treatment and analysis through the thematic content analysis technique, which comprises the phases: pre-analysis; exploration of the material and treatment of the data. 10n the pre-analysis phase, each interview was subject to floating reading, highlighting the points of interest; followed by the exploration, which consisted in the detailed and exhaustive reading of the entire material and the coding of the messages in the corpus. 10The selection of significant statements revealed the cores of meaning, which gave rise to thematic groups (categories) that permitted inferences and interpretations. 10n accordance with the methodological framework of this study, 10 the data were categorized in accordance with the semantic criterion of the content of the material collected, that is, by combining the statements that share a common theme or topic.
In the presentation of the results, the excerpts/ citations from the reports were edited to correct possible grammatical errors, without changing the content.In addition, in some parts, some terms/ words were added between brackets for the reader to better understand the content of the testimony.
To avoid the identification of each participation, at the end of each excerpt, The letter "I" was added for "Interview", followed by a number indicating the chronological order in which the data collection took place.
All ethical and legal premises were complied with, in accordance with National Health Council resolution 466/2012, and this research project has been registered under CAAE: 28867014.7.0000.0104and opinion 691.924 of the Permanent Ethics Committee for Research Involving Human Beings (Copep) at Universidade Estadual de Maringá (UEM).

RESULTS AND DISCUSSION
Twenty-three professionals were interviewed.Fifteen of them worked at patient care services (seven nurses; two auxiliary nurses; two pharmacists; one physician, one social worker; one psychologist and one nutritionist).The remainder (8) were active at administrative services (one quality manager; two cost analysts; two administrative technicians; one lawyer; one accountant and one commercial analyst).
Concerning the personal data, the participants' age ranged between 32 and 55 years; the maximum length of experience at the hospital was 30 years and the minimum two years.The majority (20) was female and married (12).
From the content analysis of the interviews, three categories were apprehended: Disqualification of the certification by the Accreditation: causes indicated by workers; Negative feelings related to the disqualification of the certification by the Accreditation and; Disqualification of the certification: insufficient reason to abandon the principles of Accreditation.

Disqualification of the certification by the Accreditation: causes indicated by workers
In this category, it could be revealed that the disqualification of the certification by the hospital Accreditation took place because the top manage-ment chose to drop out of the process.According to the interviewees, the hospital management decided to decline the hospital certification Accredited with Excellence due to the occurrence of a sentinel event: what we call a sentinel event in the Accreditation happened [...].And, as I said, we had ongoing processes, processes we had not finished yet.In addition, the board did not feel secure to continue and he [the hospital Director] decided not to do the maintenance (I2); The disqualification was due to a sentinel event that happened here at the hospital.[...] we already had some questions to reconsider.So he [the hospital Director] chose to stop the process (I4).
It is known that a sentinel event is considered to be a quality indicator at health institutions because these are characterized as severe, unwanted and often avoidable events. 11] Concerning the management decision towards the disqualification of the Accreditation certification, caused by the occurrence of a sentinel event, this attitude may have been precipitated, because the ONA establishes forms of notifying and managing sentinel events 3 which, although unwanted, happen somewhat frequently at the hospital services, even at accredited ones. 135] In view of the above, the occurrence of sentinel/adverse events is truly an important matter to maintain the accreditation, as their prevention seems to have been considered more seriously at the services that comply with the certification process.Perhaps that is why the top management at the research institution considered the occurrence of the event with that much austerity.
In line with the above, a recent and comprehensive study undertaken at 73 hospitals in European countries affirms that, although no type of hospital quality assessments presents impacts on clinical quality separately, the hospitals that were certified and accredited obtained more favorable results related to patient safety, like in the management of cerebrovascular accident. 13 should be weighted that the excerpts presented indicate that, besides the occurrence of the sentinel event, the research hospital needed to implement and/or monitor some processes related to the Accreditation which, associated with the occurrence of the adverse event, disseminated in the media, resulted in the management decision to give up the certification.
We had a severe adverse event that was disseminated in the media.So, before losing it [the certification], he [the hospital Director] found it better to drop out of the Accreditation process (I16); A sentinel event happened here at the hospital.And that was spread in the media [...].That added up to our maintenance, as we already had some weak points.So he [the hospital Director] returned the certificate, you see? (I1); We had a problem on one occasion when delivering care [...].Unfortunately it was disseminated in the media and our superintendence found it better not to apply for the revalidation of level three (I21).
Nowadays, in view of the increasing globalization and speedy dissemination of information, the media exerts important influence on the supply of health services and on the search for this information by the population. 16Thus, in combination with the need to align the work processes, necessary to maintain the hospital certification Accredited with Excellence, the fact that the sentinel event, which according to the excerpt from interview 16 was severe, was disseminated in the media, was the main factor influencing the management decision to return the certification of Accredited hospital.
It should be highlighted that all testimonies referred to the management decision on the return of the certification as an isolated act of the top management.This is relevant as, since the hospital had previously been certified as Accredited with Excellence, which according to ONA reached parameters of excellence in management, 3 the decisions were expected to be based on the principles of collegiate management, which consists in the decentralization of the decisions and approximation of the team members in the health work. 17 short, it was verified that the professionals perceived the disqualification process of the Accreditation certificate as a punctual decision of the top hospital management and this made these subjects express resentment in this regard.

Negative feelings on the disqualification of the certification by the hospital Accreditation
The disqualification of the Accreditation certificate aroused feelings of loss, sadness, anguish, disappointment and frustration: look, for me, for example [...], I cried a lot that day [the certification was canceled].When I got back I had the impression I had found another hospital.There was no longer the same motivation (I1); I thought it was frustrating!Frustrating because of seven long years to get there.That's the reason for the feeling that we lost (I5); In my professional opinion, I thought it was very bad, because there's hard work in there (I15).
The feelings expressed in the testimonies may be legitimate and justifiable because the successful achievement and maintenance of the certification by the hospital accreditation demands hard teamwork; strengthening of multidisciplinarity; overcoming of paradigms and incorporation of the comprehensive care logic to achieve the desired quality. 5Thus, in view of the cancelation of the certification, which certainly derived from incessant work by different organizational actors, it is natural for them to express feelings of defeat even discouragement in response to the disqualification.
The literature states that health workers feel that they participate in the successful implementation and maintenance of the Accreditation as, in this process, there is a feeling of mutual accountability among all stakeholders and that produces satisfaction and job in the work environment. 5In contrast with this assertion, the loss of the certification also resulted in the following feelings: I perceive [the cancelation of the certification] as a great professional defeat.So, if in these years of work I could appoint one source of sadness, the loss of the hospital certification was one of the biggest for me (I22); Look, this fact [the cancelation of the certification] for who works here, in a way, left a feeling of loss.So it disrupts people (I2);

Completely losing the Accreditation certificate was really sad for us (I16).
It is notable that the content of the testimonies in this thematic category are loaded with grief.In addition, during the data collection, it was perceived that, when the professionals appointed the disqualification of the hospital's accreditation certificate, they expressed this fact with sadness and disappointment.Thus, it is important for the organization to demand investments related to the motivation at work, through management focused on people, with a view to overcoming the event that caused the negative feelings and thus facilitate the return to the previous motivation levels. 1 To manage the negative feelings related to the cancelation of the Accreditation certificate, the nurses' role can be highlighted because their situational leadership and continuing education of the health team can lever the motivation levels at work and also contribute to decision making in favor of a new certification, in case the organization targets this. 9,18espite the lack of literature to compare results related to what is presented here, the feelings the interviewed professionals expressed can be experienced by other workers in similar realities (loss of certification), as the implementation and maintenance of the Accreditation process demand hard work, use of different resources and a feeling of sharing the required responsibilities.Thus, it is fundamental for the hospital quality management leaders and team to be prepared to manage possible conflicts and negative feelings of the workers who experience the lowering or loss of the certification.
Both the management and care professionals made excessive references to negative feelings related to the hospital's disqualification.Nevertheless, the participants expressed that the essence of the Accreditation system did not cease to exist as, despite the loss of certification, its principles remained active in the hospital's daily reality.

Disqualification of the certification: insufficient motive to abandon the Accreditation principles
The Accreditation logic and methods are based on the rationalization of work; standardization of techniques and use of management tools that are normally use in other contexts, entailing changes in the work process. 3,6,9In line with this assertion, the interviewed professionals referred that the cancelation of the certification did not directly impose the loss of important Accreditation principles: [...] but then, thinking afterwards, we returned the certificate, but not the process, you see? (I1); All processes we used to accomplish were maintained and continue [...].This means that, in fact, you don't do it just to be Accredited, but that you understood the Accreditation process and saw how important this is (I12); The people continue working as if the hospital were still Accredited.It's not the paper [the certification] that will make the difference.(I14).
The abovementioned excerpts are considered very important because, as mentioned, the Accreditation process may or may not result in a quality certification.Nevertheless, due to the fact that its logic is essentially based on the organization's continuing education instead of the bureaucratic form of surveillance, 3,5 it is clear that, despite the plausible suffering caused to the professionals deriving from the cancelation of the certification, the organization seems to have understood the essence of the Accreditation process because the professionals' reports indicate that the cancelation by itself did not impose the complete loss of the process.
It is weighed that interview 14's statement, mentioning that the paper, i.e. the certificate, does not make a difference, should be questioned because many hospital are inserted in the competitive and globalized world of service organizations and, thus, the Accreditation can be a differential for the institution's insertion and survival in the market and certainly a welcome fruit of hard work.Hence, in line with the literature, 5 the title of Accredited hospital indicates that the institution campaigns for quality and this deserves proper celebration by all stakeholders.
Other interviewees support the core of this theme category, affirming that the disqualification did not degenerate the gains resulting from the accreditation.Despite having lost the certification, our sign is the quality.Everything we do today is aimed at quality, using the [quality] tools the Accreditation taught us (I21); We continue working as if we were accredited.So, the [quality] tools have been used since their implementation.Everything continued (I18); Also because I think that quality, what was conquered and developed using tools, is not lost.It's a learning experience!The fact that there are situations that made it impossible to revalidate the certification does not disregard the whole effort and conquests the hospital achieved (I6).
Although contrasting, the results listed in this theme category do not contradict the results presented in the previous category because the interviewed professionals expressed negative feelings towards the loss of the Accreditation certificate and the content of what is discussed in this theme is more profound, as the voice of the same people indicates that what was maintained with regard to the Accreditation principles, such as the quality management and culture, surpass the mere condition of accredited hospital.
The analysis of the statements by interviews 21, 18 and 6 reveals that the learning, in this case specifically the learning originating in specific tools, used in the Accreditation context, represented a permanent gain for the organization, despite the cancelation of its certification.That is important because the Accreditation develops ongoing cycles of learning and improvements that culminate in the enhancement of the health care quality and this means much more than the certification itself. 6e quality tools are techniques used to define, measure, analyze and propose solutions to problems that can interfere in the work process and; in the context of the accreditation, the use of the PDCA (Plan, Do, Check, Act) cycle is highlighted; flow charts; checklists, brainstorming and others, adapted to the reality and needs of the organization. 2n that sense, it is apparent that the above citations are relevant, as they converge to the reflection that, despite having lost the accreditation certificate, the hospital continues using the quality tools.
0][21] In addition, the objective assessment through structure, process and outcome indicators can support the making of decisions that favor the (re)planning in the continuous improvement process, 21 an activity that is the framework of the accreditation. 3,5oncerning the use of indicators, some participants appointed that the disqualification of the certification did not lead to the loss of this practice: this spirit of the Accreditation was never lost [...] the indicators are still monitored (I7); [...] in terms of assessment [the Quality Office] strongly asks for the monitoring of the indicators.We maintained that (I11).
The above excerpts support the logic that, when the hospital reached the level Accredited with Excellence, it adhered to the premise concerning the verification of preset indicators for this title and, what is more, maintained it after the certification had been canceled. 3In the research context, this information is relevant because the measuring and analysis of indicators is one of the main criteria to achieve the certificate of Accreditation with Excellence, as the institution that acquires this seal should prove that its results, usually represented by indicators, are aligned with its strategic planning. 3,19he results of this category indicate that the Accreditation, through its logic and well-defined methods, can profoundly alter the work process of a hospital organization.That was verified through the citations, in which the workers affirm that, despite the cancelation of the certification, the organization remained keen on using the tools and aspiring to quality.

FINAL CONSIDERATIONS
Based on the results, a phenomenon could be analyzed that has not been described in the literature yet, which is: the professionals' perceptions of the disqualification of the certification by the Accreditation of the hospital where they work.
It was verified that, in the research context, the disqualification resulted from a management decision, linked to the occurrence of a sentinel event disseminated by the media.This decision aroused negative feelings among the managers and professionals who work directly with the user/patient but, nevertheless, their perceptions indicate that the organizations maintained the principles and tools of the Accreditation and of quality management.
In conclusion, at the research institution, the loss of the certification by the Accreditation caused a profound feeling of grief and even discouragement in the workers.Nevertheless, as it favors the quality of care, the essential principles of this quality management system and some of the actions implemented continued active even when the certification was disqualified.
Given the research limitations, related to the impossibility of making inferences to other realities, further research is suggested to measure the impact (final, user/professional satisfaction, care and management quality indicators, among others) of health institutions' disqualification by the hospital accreditation.
Despite this limitation, this study offers at least one important contribution, especially regarding the managers and workers' preparation to prevent and/or accept the disqualification of the accreditation certification, due to the occurrence of adverse events.In addition, the internalization of the hospital accreditation logic as an independent factor of the certification was undoubtedly a great finding.