ACREDITAÇÃO INTERNACIONAL EM HOSPITAL BRASILEIRO : PERSPECTIVAS DA EQUIPE MULTIPROFISSIONAL INTERNATIONAL ACCREDITATION IN A BRAZILIAN HOSPITAL : PERSPECTIVES OF THE MULTIPROFESSIONAL TEAM

Objective: to understand the perceptions of professionals about the implications of International Accreditation. Method: a qualitative, descriptive and exploratory study carried out with 23 workers from the multiprofessional team of a Brazilian private hospital, certified by Accreditation International, Accreditation Canada International, who answered a semi-structured, recorded interview. The data were analyzed using the Thematic Content Analysis technique. Results: from the speeches, three categories were apprehended: Accreditation provides professional satisfaction and recognition; Accreditation: Incentive to the practice of the Permanent Education in Health and; International Accreditation promotes improvements in the work process. Conclusion: workers perceived International Accreditation as a resource that (re) directed to quality management practices, promoted improvements in human capital and increased safety culture. Descriptors: Hospital Accreditation; Quality Management; International Organization; Patient Care Team. RESUMEN Objetivo: aprehender las percepciones de profesionales acerca de las implicaciones de la Acreditación Internacional. Método: estudio cualitativo, descriptivo y exploratorio, realizado con 23 trabajadores del equipo multiprofesional de un hospital privado brasileño, certificado por la Acreditación Internacional, modelo Accreditation Canada International, que respondieron a una entrevista semiestructurada, grabada. Los datos fueron analizados por la técnica del Análisis de Contenido Temático. Resultados: de las hablas, se aprehendieron tres categorías: La Acreditación proporciona satisfacción y reconocimiento profesional; Acreditación: Incentivo a la práctica de la Educación Permanente en Salud; La Acreditación Internacional promueve mejoras en el proceso de trabajo. Conclusión: los trabajadores percibieron la Acreditación internacional como recurso que (re) dirigió a las prácticas de gestión de la calidad, promovió mejoras en el capital humano e incrementó la cultura de seguridad. Descriptores: Acreditación de Hospitales; Gestión de la Calidad; Organización Internacional; Grupo de Atención al Paciente. Enfermeira, Mestre em Enfermagem, Hospital Santa Casa de Maringá. Maringá (PR), Brasil. E-mail: andressam_dias@yahoo.com.br; Enfermeiro, Mestre em Enfermagem, Professor Assistente, Universidade Estadual de Oeste do Paraná. Cascavel (PR), Brasil. E-mail: enfjoaolcampos@yahoo.com.br; Enfermeira, Professor Doutor, Centro Universitário Ingá. Maringá (PR), Brasil. E-mail: kellyelais@hotmail.com; Enfermeira, Mestre em Enfermagem, Hospital Uopeccan Filial Umuarama. Maringá (PR), Brasil. E-mail: ingrid_imav@hotmail.com; Enfermeira, Professor Mestre, Universidade Estadual de Maringá. Maringá (PR), Brasil. E-mail: vivianimeireles@gmail.com; Enfermeira, Professor Doutor, Universidade Estadual de Maringá. Maringá (PR), Brasil. E-mail: lauramisuem@gmail.com ARTIGO ORIGINAL Ferreira AMD, Oliveira JLC de, Inoue KC et al. Acreditação internacional em hospital brasileiro... Português/Inglês Rev enferm UFPE on line., Recife, 11(Supl. 12):5177-85, dez., 2017 5178 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v11i12a25094p5177-5185-2017 A qualidade de bens e serviços tem se tornado motivo de competitividade entre as empresas e preocupação em estruturar sistemas de controle e inspeção que, tardiamente, resultaram na gestão pela qualidade, implementada também na área da saúde. Na saúde, a qualidade pode ser alcançada quando há segurança no cuidado e atendimento sinérgico das expectativas dos clientes e seus familiares, dos objetivos organizacionais e da satisfação dos trabalhadores, portanto, processos sistemáticos de avaliação podem gerar informações importantes à tomada de decisão que fundamentam ações para a melhoria contínua da assistência. A avaliação da qualidade na saúde tem potencial para concatenar as propostas das organizações ao alcance da satisfação dos seus clientes, contudo, é uma ação gerencial e contingencial complexa, a qual se relaciona à resolutividade dos serviços, em consonância com a evolução das demandas de cuidado. Nesse sentido, a avaliação da qualidade hospitalar tem ganhado representatividade internacional pelo sistema que se conhece como Acreditação. Ao considerar que a elucidação de questões relacionadas à Acreditação Internacional pode fomentar discussões quanto à adesão desse sistema pelas instituições brasileiras, questiona-se: Como a Acreditação Internacional é percebida pelos profissionais que a vivenciam? Assim, o objetivo deste estudo consiste em apreender as percepções de profissionais acerca das implicações da Acreditação Internacional em um hospital brasileiro. A Acreditação é reconhecida como o processo de avaliação sistemático, periódico e reservado, pautado à luz da apreciação da realidade organizacional, sob padrões previamente definidos, que pode resultar em uma certificação da qualidade. Trata-se de um sistema de gestão que surgiu na década de 1950, com a criação da Joint Comission on Accreditation of Hospitals (JCAH), hodiernamente denominada como Joint Comission Internacional (JCI), órgão de maior representatividade da Acreditação mundialmente. No Brasil, a Acreditação é, normalmente, mediada pela Organização Nacional de Acreditação (ONA), entidade não governamental, fundada em 1999, cujo processo avaliativo baseia-se em padrões de conformidade (certificação) em três níveis, Acreditado, Acreditado Pleno e Acreditado com Excelência, cada um com níveis crescentes de exigência pautados no atendimento seguro até a excelência em gestão, comprovada pelo planejamento estratégico alinhado aos resultados. Dado o caráter voluntário da adesão ao processo em questão, existem, nacionalmente, iniciativas de Acreditação coexistentes com o modelo da ONA provindas, inclusive, de outros países. Nesse aspecto, a Acreditação internacional canadense, modelo Accreditation Canada International (ACI), utiliza metodologia direcionada para padrões de alta performance em qualidade, por meio do uso de plataforma informatizada que viabiliza o monitoramento de indicadores de desempenho e o resultado, além de orientações de especialistas internacionais para a melhoria contínua. Apesar dos benefícios importantes que alicerçam a qualidade hospitalar, viabilizados pela Acreditação, como a promoção da cultura da qualidade, o fortalecimento da equipe multidisciplinar, padrões positivos de conformidade de indicadores relacionados a eventos adversos, atendimento centralizado no usuário e respeito aos seus direitos, no Brasil, o número de instituições certificadas, ainda que crescente, é muito reduzido. Essa quantidade é mais restrita se limitada àqueles que possuem certificação no modelo ACI, que totalizam 32 hospitais. Assim, ao considerar que a elucidação de questões relacionadas à Acreditação Internacional pode fomentar discussões quanto à adesão desse sistema pelas instituições brasileiras, questiona-se: Como a Acreditação Internacional é percebida pelos profissionais que a vivenciam? ● Apreender as percepções de profissionais acerca das implicações da Acreditação Internacional. Estudo qualitativo, descritivo e exploratório, realizado em maio de 2014 em um hospital privado de uma capital do Sul do Brasil certificado pela Acreditação Internacional, modelo ACI, desde 2010. A população de estudo foi constituída por todos os profissionais atuantes no hospital, independente da função, setor e/ou nível hierárquico, desde que respeitassem o seguinte critério de inclusão: estarem empregados na organização, pelo menos, durante a última avaliação externa para a INTRODUÇÃO

English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5177-85, Dec., 2017 5178 The quality of goods and services has become a reason for competitiveness among companies, and a concern in structuring control and inspection systems 1 , which, later on, resulted in quality management, also implemented in the health area. 2 In health, quality can be achieved when there is security in the care and synergistic fulfillment of client and family expectations, organizational goals and employee satisfaction. 2Thus, systematic evaluation processes can generate important information for decision-making that underlies the continuous improvement of care. 3e evaluation of health quality has the potential to link organizations' proposals to the satisfaction of their clients, 2-3 however, it is a complex managerial and contingent action, which is related to the service's resoluteness, in line with the evolution of the In this sense, the evaluation of hospital quality has gained international representativeness by the system known as Acreditação. 2,4hen considering that the elucidation of issues related to International Accreditation can foster discussions about the adhesion of this system by Brazilian institutions, the question is: How is International Accreditation perceived by the professionals who live it?Thus, the objective of this study is to understand the perceptions of professionals about the implications of International Accreditation in a Brazilian hospital.
6] This is a management system that emerged in the 1950s, with the creation of the Joint Commission on Accreditation of Hospitals (JCAH), now known as the International Joint Commission (IJC), the most representative body of Accreditation worldwide. 7n Brazil, Accreditation is usually mediated by the National Accreditation Organization (NAO), a nongovernmental organization, founded in 1999, whose evaluation process is based on standards of compliance (certification) at three levels, Accredited, Fully Accredited and Accredited with Excellence, 4.6 each with increasing levels of requirement, based on the safe attendance to the excellence in management.This, as evidenced by the results-oriented strategic planning. 2,6ven the voluntary nature of adherence to the process in question, there are national Accreditation initiatives coexisting with the NAO model, including from other countries. 4In this respect, the Canada International Accreditation (CIA) International Accreditation uses a targeted methodology to standards of high performance in quality, through the use of a computerized platform that enables the monitoring of performance and the result indicators, as well as guidelines from international specialists for the continuous improvement. 8espite the important benefits that underpin the hospital quality, made possible by Accreditation, such as the promotion of quality culture, the strengthening the multidisciplinary team, positive compliance standards for indicators related to adverse events, centralized user care and respect for their rights, 2.7 in Brazil, the number of certified institutions, albeit growing, is very small. 9This amount is more limited if limited to those who have certification in the ACI model, which totals 32 hospitals. 8hus, when considering that the elucidation of issues related to International Accreditation can foster discussions about the adherence of this system by Brazilian institutions, it is questioned: How is International Accreditation perceived by professionals that experience it?
• To understand the perceptions of professionals about the implications of International Accreditation.
Qualitative, descriptive and exploratory study, conducted in May 2014 in a private hospital in a capital of southern Brazil, certified by International Accreditation, model CIA, since 2010.
The study population consisted of all professionals working in the hospital, regardless of their role, sector and / or hierarchical level, provided they met the following inclusion criteria: they were employed in the organization, at least,

INTRODUCTION
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5177-85, Dec., 2017 5179 during the last external evaluation for International Accreditation certification.The non-probabilistic sample consisted of 23 workers selected for convenience.Participants were approached in the workplace and invited to participate in the study by clarifying the purpose of the same and their way of driving.After the previous acceptance and signing of the Free and Informed Consent Term (FICT), the participants completed a form for sociodemographic and the professional characterization and, later, they were taken to the recorded interview and guided by the following question: "Tell me about the certification of International Accreditation of this hospital." The interviews were concluded when the researcher realized the scope of the proposed objective, represented by the successive repetition of the content of the testimonies.After the data collection phase, the empirical material was transcribed in its entirety and submitted to Content Analysis, thematic modality, respecting the pre-analysis stages, exploitation and processing. 10n the presentation of the results, excerpts / excerpts / verbatins were edited, without alteration in the content / sense of the speeches.To ensure the anonymity of the participants, the interviews were identified with the letter "E", followed by an Arabic numeral, which indicates the chronological order of the transcript.
All From the analysis of the interviews, three categories were seized: Accreditation provides professional satisfaction and recognition; Accreditation: Incentive to the practice of the Permanent Education in Health and; International Accreditation promotes improvements in the work process.For better understanding, the content of the latter category was divided into two subtopics.

 Accreditation provides professional recognition and recognition
Participants report their sense of professional satisfaction at working for an institution accredited by International Accreditation, through improvements in care, evidenced from the results obtained in the arduous certification process:

This is very cool (E20).
Another feeling present in the speeches was the recognition of the organization as a whole, as can be seen in the following excerpts:

[...] you are inside an institution that is looking for the best. After all, the hospital exists to take care of lives and if we do it better than the other hospitals. It's very good for us (E10). [...] work in an [internationally certified] company that, whether you like it or not, looks good out there, is respected. It is good that you have this respect from your competitors (E9).
According to the statements presented, the Accredited institution achieves the internal respect of its employees, as well as the recognition of the external public, and, consequently, the feeling of professional satisfaction, through the valorization of the work done and actions directed at the professional, among them, the development of new knowledge.

RESULTS
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5177-85, Dec., 2017 5180 The construction of knowledge, demanded by the International Accreditation, besides improving preexisting skills, provides the development of new skills.This premise can be observed in the following extracts:

[...] I grew up as a professional. I think I became a better doctor after I went through quality management, provided by Accreditation (E4). I think this [participation in the International Accreditation process], for any professional, adds [value] to their curriculum, not only as a person, but, also, as a professional (E7).
When considering that the requirements in the professional qualification tend to be differentiated to the attendance of the questions to the certification, the incentive to the development of new knowledge is considering a differential of the institution: In this way, the participants perceive the accreditation process as an opportunity for qualification and professional growth, by encouraging the development of new skills.

 International Accreditation promotes improvements in the work process
Participants reported that international certification has driven systemic changes with a view to quality of care.For a better understanding of the content of the reports, this category has been divided into two subthemes: The equipment also has to change [by the adhesion of the international certification], because many equipment needed to be acquired for both professional, and patient safety (E14).Thus, the accreditation process promotes improvements in the care provided, by engaging the institution in favor of a safety culture and improving care processes and its infra-structure.
From the results, it is possible to verify that the Accreditation provides satisfaction and professional recognition, encourages the practice of Permanent Education in Health, and promotes improvements in the work process, with regard to the standardization of manuals and routines, and the development of culture of security.The expressive portion of Nursing professionals, especially nurses, is justified by their primary participation in the planning of actions according to Accreditation programs, their performance in the managerial, care and intermediary field among different intrahospital services. 11ctively participating in management processes, such as those required by Accreditation, can impart a feeling of satisfaction to the professional and strengthen bonds of trust between the manager and the manager because it promotes a better environment for effective communication and active posture throughout the process. 12,133] In Accreditation methodology, including international, where quality is known as the essential purpose, 4,6,8 aggregating satisfaction with human capital can be a valuable weapon within the scope of qualified assistance.
The feelings of accomplishment and coresponsibility enable the professional to perceive themselves as a transforming agent and, consequently, to identify himself with the process in which he is inserted. 2,14These feelings possibly motivate a change in the organizational culture that, no doubt , is one of the objectives of International Accreditation, which values the culture of quality. 8 line with the above, it should be pointed out that the "evaluation perspective", not commonly seen in hospital organizations is frequent in the context of international accreditation and also indicates the occurrence of a profound change in the organization's culture.In addition, the perspective of continuous evaluation, associated to the feeling of satisfaction and pride, is relevant, since, normally, the professionals who work in hospital institutions are resistant to the evaluation processes. 1he institutional development, based on evidence and optimization of applied investments, besides giving credibility to the organization, 12 can also generate a sense of pride to the professionals. 2 In this aspect, the testimonies denote that the Accredited institution gains synergistically internal respect on the part of the human capital, but, also, external, by population/society.
Recognition related to the feeling of satisfaction can result from the valorization of the professional exercise and the knowledge that the same acquires and / or improves during the Accreditation process, making the employees active agents and transformers of the practice.For this, the certification itself, may not be enough, and the organization needs to make investments to qualify its employees.
] The qualification of health workers, through Permanent Health Education (PHE), is in line with the proposal of the Unified Health System (UHS), 15 which proposes the development of critical and reflexive agents in the world of work, so that changes are effective.This fact certainly leads to the valorization of the worker and the greater

DISCUSSION
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5177-85, Dec., 2017 5182 visibility of the population, of its professional category. 5By encouraging the construction of new knowledge, Accreditation recognizes the importance of the human factor to the achievement of improvements in the process 6 .For this, it is important to link management strategies with educational actions to professional improvement. 11ontinuing education, which is not limited to formal training initiatives such as training and continuing education activities, but, also, as a strategy for discussion, restructuring and innovation of the work process, must be applied in the course of Accreditation, since it is a tool that improves and transforms care practice. 2ccreditation determines a constant process of learning at all organizational levels and, therefore, should be a source of interest and investment by the institution's leaders. 6After all, the positive results may emerge from the applicability of these knowledge in care practice and strategic planning.
5] Thus, the work environment configures as a space for joint and interrelational action, in which the creation of means of communication and discussion of the process is required, in order to promote permanent education and the culture of continuous improvement among all organizational agents. 16n spite of the importance of the partnership between managers and other professionals, the statements of the deponents (with emphasis on E1) show that the viability of the improvements of the work process, mediated by the people, is possibly very much related to the formal training and qualification practices.This is certainly important, but, it may not be sufficient, to provide the criticality of workers in the active pursuit of changes in their professional profile.
The (re) construction of the professional profile is possible based on permanent educational actions on the work process of the organization and search for the quality of the service provided.According to the International Accreditation system, these practices should cover all professionals in the institution, 8.13 in order to reshape the culture and organizational climate.Therefore, it is necessary to develop actions to raise awareness and inclusion of the different categories, given that sectoral interrelationships are determinant to the operationalization of the certification process. 16rom the point of view of professional valuation, a new concept of People Management emerges, which requires action flexibility, review and maintenance of strategies in order to enable the agents to be co-responsible and encourage them to adopt new professional and even personal behaviors.13 In this respect, it appears that International Accreditation is an addendum to innovative practices in the management of human capital.
The certification, in addition to boosting professional development, also promotes the rationalization of the work process, with a view to positive changes in it, being a product expected in the adhesion of Accreditation. 6rom the statements expressed by the exponents, the standardization of norms and routines and the development of safety culture, as strategies to improve the work process in view of promoting patient safety.
The methodology adopted by CIA consists of structuring and evaluating indicators through a computerized platform and this contributes to the planning of evidencebased actions, formulation of situational diagnoses and decision making.It therefore gives legitimacy to the work process, 8 by validating a set of standards and practices that are standardized and recognized by the service.
It is recognized that, although there is uniformity attributed to actions legitimized in health services, the caring process is dynamic and unpredictable.With this, it is often necessary to flexibilize the conduits, in order to offer assistance confluent to the needs of the patient / client.
In spite of the importance of flexibilizing behaviors, standardization in the health care process calls for the creation of strategies that enable the maintenance of established protocols6 and this can be guaranteed through internal auditing, that has as main objective to monitor and advise units hospital care in the execution of defined care processes. 16Considering that English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5177-85, Dec., 2017 5183 the health area is dynamic, it is pertinent to evaluate the feasibility and the results of the proposed actions.In this sense, the use of indicators can be an important resource in the analysis of institutional performance. 16though Accreditation provides benefits to its agents, a study 17 points out that the high level of demands and regulations demanded from nurses working in accredited hospitals may reflect negatively on care due to the need to carry out the processes rigorously.In contrast to the previous reflection, the speeches expressed by the participants indicate that international Accreditation, in addition to favoring professional satisfaction, training and; the standardization of care processes, promotes the culture of patient safety.
][14][15][16] This information corresponds to what CIA says, which attributes patient safety and good practices to the standardization of care routines to improve institutional performance. 13 The adoption of organizational strategies to promote patient safety is in line with the proposal of the Ministry of Health, 18 on the creation of a safety culture within health institutions.From this perspective, the safety culture is structured in operational characteristics that encompass the obtaining and the optimization of several resources to maintain safety, organizational learning, through the occurrence of adverse events, and co-responsibility in the prevention and identification of possible failures. 18herefore, patient safety is a primary requirement in the provision of care, and one of the main requirements of quality management, as an institutional goal of great relevance for the organizational culture focused on continuous improvement.
The promotion of security, in addition to being an objective of Accreditation, needs to be a focus of the commitment of the top management, since all hierarchical levels must act together in order for this precept to be incorporated into institutional policy, and can be seen as a challenge for the managers due to the various structural adjustments required. 5,11he quality indicators evaluated by the Canadian model, besides encompassing the patient care and the professional qualification, also verify the availability and the maintenance of equipment used in the care process. 13n considering that International Accreditation establishes patient safety as one of the goals of the system, the integration of actions favors the reduction of adverse events and rationalizes financial resources.Considering that certification promotes the alignment of the institution's work process, in establishing standards and procedures, 8,13,19 resource management is directed towards the acquisition and optimization of materials and equipment that are appropriate for the action plan.
Despite the interest of health institutions for international certification, literature 4 points out that there is a small number of institutions that have, clear values, increasing safety from the perspectives of users and the family.This gap makes it possible to assess the repercussions of quality management for the patient, a challenge launched in the next studies, 5 since Accreditation alone may not guarantee user satisfaction 20 and, therefore, it is conjectured that there is the need to carry out systematized institutional evaluations, aimed at the investigation of the results perceived by the users attended in accredited institutions.