INTRODUCTION

The social, economic and productive process transformations that come with globalization and the consequent increases in healthcare competition demand changes in healthcare organizations. As a result, these organizations started reviewing their management models aiming to improve the quality of services they provide. One of the tools that have been used in this process is the implementation of programs for healthcare accreditation¹.

Accreditation is a voluntary formal process by which a recognized body evaluate and recognize healthcare organizations that meet applicable pre-determined published standards, and seek continuous improvement²⁾⁽³⁾. The goals of accreditation include assessment of quality and safety in healthcare; development of a culture of quality through the participation of professionals in the process; and attainment of external recognition⁴.

In Brazil, accreditation has been implemented since 80´s, based in the Joint Commission International (JCI) standards. The implementation of the Brazilian accreditation program took place in 1999 and it was named “National Accreditation Organization” (ONA, per its acronym in Portuguese). It was conducted by a private organization without economic order and collective interest. The main purpose is the implementation at the national level of an ongoing process of improving health care quality, encouraging all health services to reach high quality standards⁵.

ONA’s evaluation is done considering the standards of a model for assessing quality that is based on Structure, Process and Outcome, and provides three levels of certification. To reach the first level, the hospital must be in accordance with the criteria for patient safety in all areas of activity, including structural and service issues. The second level has, in addition to the criteria of safety, integrated management, with processes taking place fluidly and good communication between activities. is the "excellence in management". It should be noted that, an organization or health both certifications are valid for two years. In the third level, the hospital becomes accredited with excellence. The principle of these level Programs accredited with excellence already reached the levels 1 and 2 previously, in addition to the specific standards of level 3. The institution must already demonstrate an organizational culture of continuous improvement with institutional maturity. This certification is valid for three years⁵⁾.

In Brazil ONA and JCI are responsible for the majority of accreditation processes in hospitals. Both developed a number of standards focused in processes, but the JCI process has the main evaluation focused on indicators related to the care process for patients and humanization. Aims to promote the continuous improvement of care in health institutions, through international standards, international goals of patient safety and care with monitoring by indicators. JCI is represented in Brazil by the Brazilian Accreditation Consortium (CBA, per its acronym in Portuguese). Currently it has 27 hospitals certifications and ONA is responsible for 230 certifications⁶⁾⁽⁷.

Since 2013, Brazilian hospitals also using the tool of Canadian Council on Health Services Accreditation, currently 25 hospitals have this certification already⁸.

The development of countries, their culture, the education of professionals, and mainly its population awareness about the right to receive quality care, are directly related to the accreditation process⁹. Literature has presented studies with evidence of the impact of accreditation programs in healthcare services¹⁰_, and highlight that professionals who take leadership roles in these processes are generally nursing managers¹¹⁾⁽¹².

Nursing staff is critical to the development of a quality program in hospitals, due to the substantial number of professionals, and their direct and permanent performance assisting internal and external customers¹³. In this sense, accreditation processes are influenced by the actions of nursing leaders and, at the same time, have important implications for the day-to-day work of the team^{(13 )} ,specifically, improved team work and productivity¹⁴.

Despite the significant growth of accreditation programs, knowing whether and how these programs have affected the quality of healthcare services has been considered a challenge to certification agencies, governments, society and healthcare services¹⁰.

OBJETIVO

To evaluate the impact of hospital accreditation programs from the perspectives of nurses.

METHOD

This paper was generated from a multicenter project developed by the Research Group from Ribeirão Preto School of Nursing at University of São Paulo, which intends to analyze and compare the results of the implementation of Participatory Management and the Hospital Accreditation in Brazilian and Canadian Hospitals in the view of the managers and health teams.

It is a quantitative, descriptive, exploratory study and conducted in a private general tertiary care hospital, 85 beds, located in the city of Ribeirão Preto, state of São Paulo, Brazil. This hospital is accredited with excellence by ONA since 2012.

The questionnaire was applied to a population composed by all the nurse managers (29) who worked in the hospital. The choice of this population is justified, due to the direct involvement in the conduction of processes and activities that move the organizational structure, capacity to integrate the technical and administrative knowledge and also the responsibility with the programs of quality improvement.

As an inclusion criteria, nurse had to be working at the hospital for at least twelve months, and not be on scheduled leave during data collection.

Data collection occurred from august to november, 2013 . It was used a questionnaire adapted from an international study¹⁴ which evaluate quality implementation and outcomes in health-care organizations in the context of accreditation.This questionnaire was chosen because previous study showed reliability and internal consistency with a Cronbach Alpha that exceeded 0.80 for all scales.

The questionnaire was translated into Brazilian Portuguese, and submitted for face and content validity evaluation to three experts: one professor in the area of ​​ nursing and healthcare management, a nurse working in hospital setting with experience in quality management, and a nurse manager.

The final version of the questionnaire consisted of a sociodemographic information section and a section that included 45 questions distributed in seven scales: quality results (5 items); human resources utilization (6 items); strategic quality planning (7 items); quality management (6 items); use of data related to patient satisfaction (7 items); staff involvement (5 items) and benefits of accreditation (9 items). The responses were rated on a Likert scale with five values, ranging from one to five, corresponding respectively to strongly disagree; disagree; neither agree nor disagree; agree; and strongly agree. This questionnaire allowed us to assess the level of agreement among participants regarding the accreditation program, and the score obtained (1-5 points) was assessed as proportional to the level of satisfaction of respondents.

Data were analyzed using SPSS 15.0 and a 0.05 significance level. Descriptive analysis was done to report sociodemographic information of respondents, and mean scores were computed for every scale based on the number of available items. For sociodemographic data and responses given to each item of the seven scales, we used absolute numbers and their respective percent. We present scores and standard derivations for the seven scales in the next section.

The research project was approved by the Research Ethics Committee of the Ribeirão Preto College of Nursing, University of São Paulo, protocol number 248.223/2013.

RESULTS

All the 29 respondents answered the questionnaire (100%). The predominant age was between 30-45 years (51.7%), and most subjects were female (69%). 41.4% of participants had worked between 3-4 years in the institution.

In all scales, the mean score was 3.5 points or greater, ranking perceived improvements of accreditation programs as satisfying for all domains, considering a scale from 0 to 5 for calculating the average. The Human Resources Utilization scale, which consist of questions regarding rewards, recognition, education and training had the lowest mean (3.5). The Benefits of Accreditation scale had the highest mean (4.15), and its standard deviation value ​​was 1.04.

One hundred percent of participants agreed or strongly agreed that The hospital encourages nurses to keep records of quality problems through documentation, which had the highest overall percent agreement (agree and strongly agree) in the questionnaire. It shows that the institution is concerned and adopted the use of indicators for quality assurance; also, encourages employees to notify through the Adverse Event reports and study plans, for example.

Conversely, the lowest (20.7%) overall percent agreement was for the item Nurses are given adequate time to plan for and test quality improvements. See Table 1 for the results of responses for all scales and items in the survey.

Related to Quality Results scale 93.1% of nurses agreed or strongly agreed that over the last year, the hospital had shown measurable improvements in customer satisfaction; however, only 55.1% of nurses agreed or strongly agreed that, the hospital has shown steady, measurable improvements in the quality of services provided by clinical support departments such as laboratory, pharmacy, and radiology.

Concerning the Strategic Quality Planning scale the highest percent agreement (93.1%) was the involvement of nurses in developing plans for improving quality. Nonetheless, 41.4% disagreed or strongly disagreed and 37.9% neither agreed nor disagreed that nurses are given adequate time to plan for and test quality improvements. However, 89.6% agreed that nurses play a crucial role in setting priorities for improving quality.

The scale about Human Resources Utilization showed the lowest mean (3.5), and nurses’ opinions varied widely in relation to rewards and recognition. A total of 41.4% agreed or strongly agreed; 24.1% neither agreed nor disagreed and 34.4% disagreed or strongly disagreed with the statement nurses are rewarded and recognized (e.g. financially and/or otherwise) for improving quality. 75.8% of participants agreed or strongly agreed that the hospital has an effective system for nurses to make suggestions to management on how to improve quality. In regard to education and training, within the same scale, 62.1% agreed or strongly agreed that nurses are educated and trained on how to identify and act on opportunities for quality improvement based on recommendations from accreditation surveys. 69% agreed or strongly agreed that nurses are given continuous education and training in methods that support quality improvement.

Regarding the Quality Management scale, 100% of the nurses agreed or strongly agreed when they were asked whether the hospital encourages them to keep records of quality problems through documentation. In addition, 93.1% agreed or strongly agreed that the hospital has effective policies to support improving the quality of care and services. Conversely, 17.2% disagreed or strongly disagreed that the services that the hospital provides are thoroughly tested for quality before they are implemented.

From the total, 82% of the nurses agreed or strongly agreed that patients’ complaints are studied to identify patterns and learn from them to prevent the same problems from recurring. Also, 89.7% also agreed or strongly agreed that the hospital uses data from patients to improve services in the Use of Data Related to Patient Satisfaction scale.

Related to the Staff involvement, 96.6% percent of participants agreed or strongly agreed that learning occurred as a result of recommendations made for their hospital since the last accreditation survey. In addition, 93.1% agreed or strongly agreed that these recommendations were an opportunity to implement important changes at the hospital and that they participated in the changes that resulted from accreditation recommendations.

According to the Benefits of accreditation scale, 96.6% agree or strongly agree that accreditation allows improvement of patient care, and that accreditation is a valuable tool for the hospital to implement changes. Additionally, 79.3% agreed or strongly agreed that accreditation is a stimulus for staff motivation and encouragement of teamwork and collaboration.

DISCUSSION

Nursing services face challenges to meet the demands of internal and external customers in order to achieve excellence in quality of care in the hospital setting. Nursing leaders are in privileged positions to change the quality status of healthcare services due to their professional ability to perform management activities, nursing care activities and continuous educational practices. Specialized education can inform quality criteria, and consequently staff will be better trained to implement new strategies for quality in healthcare, such as Accreditation. In more qualified services, nurses can develop innovative programs centered on new concepts of structure, aiming to achieve better quality through best practices in healthcare¹⁵⁾⁽¹⁶.

According to the nurses interviewed in a study¹³, negative aspects of accreditation were related to the lack of recognition and appreciation given the challenges imposed during this process; uneven demands for nursing professionals in comparison with professionals from other categories; little involvement of the multidisciplinary team and inexistence of cohesion among the professionals; and implementation of accreditation as something imposed by higher management, without raising professionals’ awareness first. The same study highlighted the following positive aspects: pride and satisfaction in being also responsible for the hospital's recognition in society; possibility of professional maturity; safety in the workplace, established through routines, standardization and organization of the service with material, technical and human resources more qualified and available; organizational climate that is favorable to professional learning through exchange of experiences and possibility of better chances in the labor market.

Nurses have a fundamental role in the course of accreditation process, as they actively participate in decision-making, strategy and operations. In decision-making, nurses contribute determining the guidelines and favorable conditions for the nursing service to achieve quality standards. In regard to strategy, they prepare the nursing team to achieve the goal of accreditation. In operations, nurses are able to improve the accreditation process by supervising the nursing staff in a systematic way and as part of the self-assessment team of the units in the stage of pre-hospital accreditation. In this context, the actions of the nursing team involve activities directed to the dimensions of care, management, teaching and research¹⁴.

Improvements in quality resulting from the accreditation will be mainly reflected in the care delivered to patients, which is performed not only by members of the nursing staff, but also by a multidisciplinary team. Including other professional categories in the accreditation process can add diversity of perspectives, practices and methods, with the provision of a more comprehensive and qualified health care as a result¹³.

Nurses are considered the best-suited professionals to lead the processes of quality improvements in health care institutions, due to their proximity to users, institutional commitment and their role as facilitators in the multidisciplinary health team, enabling leadership¹⁷.

Therefore, leadership development needs to be emphasized during nurses’ professional educational process. In a recent study, conducted in 14 hospitals accredited by ONA and Joint Commission International (JCI), in São Paulo, leadership was found to be the most important and recurrent competence in nursing managers in the vision of their managers¹⁷. However, during nursing education, very often technical aspects are more valued than the managerial ones. Nevertheless professional practice requires the learning of management aspects, for example when nurses are required to make decisions that can affect institutional quality and outcome.

A very interesting aspect about professional remuneration was identified and included in the scale Human Resources Utilization, as it associates salary with the evaluation of performance of the professionals individually or in groups. This adds value to ​​professional practice and contributes to professional commitment to providing qualified assistance.

Recognition and reward are important factors to determine the influence of nurses' satisfaction, performance and limitations¹⁸ It is important to discuss the power of nurses individually and of nursing as a professional category. The reason is that when looking at the effects of qualification programs on the professionals, numerous studies highlight negative effects of accreditation for nurses, such as stress and high blood pressure¹⁹⁾⁽²⁰, corroborating with another study that reports that the process of obtaining accreditation was considered a time consuming stressful experience, and that it required a great investment of resources²¹⁾.

Study conducted with 28 critical care nurses, from seven hospitals in Taiwan, showed that most of them believe that accreditation had a strong impact on managerial behavior in the hospitals, which therefore influenced their work situation. Three concepts emerged from the findings of this study: continually changing demands for preparations, organizational coping strategies and causes of stress to nurses. All nurses reported that their workload became too high during hospital accreditation²⁰.

In relation to the scale Quality Management, we observed that the hospital encourages nurses to maintain records of quality problems through documentation. The nursing record is one of the ways to demonstrate the work that is performed by the nursing staff, and also is an important indicator of nursing care quality. Incorrect reporting, especially lack of periodicity and continuity of its execution, prevents any type of assessment and accreditation, making it impossible to develop indicators and to execute prosecutions and investigations that can legally protect the professional and the institutions²².

The willingness of a hospital to attain accreditation is a sign that this institution is committed to healthcare quality, since to achieve this goal is necessary to undergo several changes and improvements. Standards and protocols are established and must be met by all professionals involved in the process.

With the implementation of accreditation, all processes that are developed by the nursing staff became standardized, which is very beneficial to the professionals, since a quality standard is acquired and must be met, in addition to being monitored along with other professionals in the healthcare team.

Accreditation implementation requires continuing education, which in turn impact improvements in nursing care. These are perceived by customers, who notice the changes that are made in respect to the quality of care provided to them. All this is important so that the improvement process be continuous and effective in reducing errors, and enabling patients to have quality service beyond what they expect.

CONCLUSION

The majority of nurses surveyed agreed that the accreditation process has brought improvements to the institution, which shows hospital commitment to quality, especially in regards to strategic quality planning, quality management, use of data related to patient satisfaction, staff involvement and benefits of accreditation. However, participants reported the need for improvements in relation to the recognition and rewards strategies. They also identified the importance of having more time to devote to accreditation activities.

Nurses surveyed demonstrated involvement with the hospital accreditation process and understanding of the concept. In this perspective, recognition of the importance and the need for quality management programs are central aspects for the continuing improvements required by hospital accreditation.

Nurses play an important role in the evaluation process, and can, along with the healthcare team, provide quality care, and in depth knowledge, considering the criteria and standards proposed for accreditation. Therefore, it is important that strategies for evaluating quality be addressed by undergraduate nursing courses.

The limitations of the study are related to the quantitative sample, which was small. Despite the nurses were intentionally chosen, the other professionals that comprise the nursing team in Brazil could have been included. Studies with a higher number of participants and other professionals of the nursing team will provide more representative results for the studied phenomenon.