RESUMPTION OF HOSPITAL ACCREDITATION IN THE ‘POST-COVID-19 PANDEMIC’ ERA: LEADERSHIP PERSPECTIVES

ABSTRACT

Objective:  To understand leaders’ perspectives on the resumption of the Hospital Accreditation process in the context of the “post-pandemic” of COVID-19.

Method:  A qualitative case study was carried out in a large university hospital in Porto Alegre (RS), Brazil. Data was collected from 10 strategic leaders from August to September 2022 through a semi-structured interview. Thematic Content Analysis was used.

Results:  Three categories emerged: “Hospital changes and strategies demanded by the COVID-19 pandemic”; “Quality management and patient safety challenges arising from the pandemic context”; and, “Managing the resumption of the post-pandemic Hospital Accreditation process”.

Conclusion:  The COVID-19 health crisis has imposed obstacles on previously well-established processes. The leadership recognized the exhaustion of the teams and worked to motivate people and spread the information necessary for the success of the quality recertification.

KEYWORDS: Hospital Accreditation; Leadership; COVID-19; Process Assessment, Health Care; Quality of Healthcare

RESUMO

Objetivo:  compreender as perspectivas de lideranças sobre a retomada ao processo de Acreditação Hospitalar no contexto da “pós-pandemia” da COVID-19.

Método:  estudo de caso, qualitativo, desenvolvido em um hospital universitário de grande porte de Porto Alegre (RS), Brasil. A coleta de dados ocorreu com 10 lideranças estratégicas de agosto a setembro de 2022 por meio de uma entrevista semiestruturada. Empregou-se a Análise de Conteúdo Temática.

Resultados:  emergiram três categorias, a saber: “Mudanças e estratégias do hospital demandadas pela pandemia da COVID-19”; “Desafios da gestão da qualidade e segurança do paciente advindas do contexto pandêmico”; e, “Gerenciamento da retomada do processo de Acreditação Hospitalar pós-pandemia”.

Conclusão:  a crise sanitária da COVID-19 impôs entraves para os processos antes bem sedimentados. As lideranças reconheceram a exaustão das equipes e trabalharam no sentido de motivar as pessoas e a capilarizar as informações necessárias ao êxito da recertificação de qualidade.

DESCRITORES: Acreditação Hospitalar; Liderança; COVID-19; Avaliação de Processos em Cuidados de Saúde; Qualidade da Assistência à Saúde

RESUMEN

Objetivo:  Conocer las perspectivas de los líderes sobre la reanudación del proceso de Acreditación Hospitalaria en el contexto de la “post-pandemia” de COVID-19.

Método:  estudio de caso cualitativo realizado en un gran hospital universitario de Porto Alegre (RS), Brasil. Se recogieron datos de 10 líderes estratégicos entre agosto y septiembre de 2022 mediante una entrevista semiestructurada. Se utilizó el análisis de contenido temático.

Resultados:  urgieron tres categorías: “Cambios y estrategias hospitalarias exigidos por la pandemia COVID-19”; “Gestión de la calidad y retos para la seguridad del paciente derivados del contexto pandémico”; y, “Gestión de la reanudación del proceso de Acreditación Hospitalaria pospandémica”.

Conclusión:  La crisis sanitaria COVID-19 ha impuesto obstáculos a procesos previamente bien establecidos. La dirección reconoció el agotamiento de los equipos y trabajó para motivar a la gente y difundir la información necesaria para el éxito de la recertificación de la calidad.

DESCRIPTORES: Acreditación hospitalaria; Liderazgo; COVID-19; Evaluación de procesos sanitarios; Calidad de la asistencia sanitaria

HIGHLIGHTS

Certification following periods of crisis relies on the engagement of leaders and teams.

The COVID-19 pandemic has left significant legacies for the quality of care.

A challenging and timely process to reclaim previously established practices.

Adversities in human resource management and time management.

INTRODUCTION

The COVID-19 pandemic has impacted the health and quality of life of healthcare workers¹. Especially when knowledge about protective measures and combating the pandemic had not yet been fully established, these professionals had deleterious consequences for their health, both because of the fear of contagion² and because of working conditions, workload, and organizational support that were not always conducive to safe care³.

The potentially collapsing reality of the pandemic demanded that managers of health systems and services, as well as those at the strategic and tactical levels of services, make political decisions to deal with it^4-5.

Considering the turbulent and dynamic scenario of the pandemic, the study focuses on the decision of a hospital to interrupt the external evaluation process for accreditation as an example of a review of organizational priorities. Accreditation consists of an external, periodic, reserved evaluation system based on previously defined standards which, if met, may or may not certify the institutions submitted to the process⁶.

Although accreditation is based on the systemic analysis of processes and teams, in many health services, the involvement of some organizational segments remains incipient, demonstrating that this transversality still needs to be explored by managers⁷. Attributing results generated directly by accreditation through measurable indicators is also a challenge since controlling variables that can generate answers as to how or why this certification decisively influences the quality of care is questionable⁸. Another point recently problematized by Chicago-based researchers concerns transparency and the sources/bases for the quality standards established by the Joint Commission⁹.

Despite the gaps above, evidence points to a relationship between patients’ perception of the quality of services and the level of accreditation the hospital has¹⁰. Other recent evidence came from a study in the United Arab Emirates, which found that accreditation sustained improvements in quality metrics during evaluation cycles, suggesting that this quality management system is reliable¹¹. Among workers, accreditation has been cited as a driver of better results regarding job satisfaction¹² and the practice environment¹³.

The practices inherent to accreditation, such as internal audits, which have been pointed out as beneficial for developing progressive improvement actions, are not identified as a priority in a pandemic scenario¹⁰. In this sense, the return to accreditation can be challenging, given that the COVID-19 pandemic has demanded dynamism and reformulation of services and processes, characteristics that have weakened and transformed them from the point of view of standardization and quality¹⁴. Knowing this recovery process from the perspective of strategic agents in healthcare organizations is useful so that, in future crises, the processes of (re)adherence and continuity of quality management initiatives can run more smoothly and assertively.

Given the problem and justification stated, this study aims to answer the following question: how do professionals in strategic leadership positions perceive the process of returning to Hospital Accreditation after experiencing the COVID-19 pandemic? To this end, the objective was to understand the leaders’ perspectives on resuming the Hospital Accreditation process in the “post-pandemic” context of COVID-19.

METHOD

This is a qualitative case study. The theoretical-philosophical assumption of the case study is permeated by the circumstances of some social phenomenon in understanding how or why this social phenomenon works through the lived experience of the individuals involved¹⁵. Therefore, the case can be studied in a community, collective, or organization - which applies in this study. This design was chosen because it allows for a systematic and detailed analysis to understand a specific situation, an individual, a small group, an institution, a program, or an event¹⁵. To ensure this study’s rigor, the checklist set out in the Consolidated Criteria for Reporting Qualitative Research (COREQ)¹⁶ was followed.

The research was conducted in a large 850-bed university hospital in southern Brazil. It was the first public teaching hospital in the country to be accredited by Joint Commission International (JCI) and received its first seal in 2013. The hospital decided to interrupt the recertification, which was due to take place in 2020, because it felt that the time was not right, given that the highest peaks of the COVID-19 pandemic were occurring. As a result, the institution lost its seal in 2020, and in 2022, it resumed the process for a new certification. In other words, it has been subjected to the assessment of quality standards just like organizations that have never been accredited, even though adherence to such standards may have been maintained without the seal.

The participants were chosen using the “snowball” sampling technique based on the concept of reference networks. It begins with a participant who is considered a key informant on the subject of the study, known as the “seed”¹⁷. In this study, the subject was the nurse responsible for the Quality Management sector of the hospital under investigation.

After the first collection, the first participant was asked to nominate another person they considered appropriate to answer the research question and the study objective, according to the chosen technique. According to reference¹⁸, the number of participants was defined when data saturation was observed. This was noticed in the seventh interview, but three more interviews were carried out for accuracy.

Participants had to meet the following eligibility criteria: be a senior professional and have worked in the hospital for at least three years; and hold a strategic leadership position in the field of study, considering the chapters of the quality standards manual of this accreditation methodology¹⁹, regarding the processes of adapting to the quality standards of the JCI international accreditation.

Data extraction occurred through semi-structured, face-to-face, recorded interviews carried out on the premises of the hospital studied and duly scheduled with each participant in September and October 2022. Before collecting the data, a pilot test was carried out with the research group members to ensure that the questions were understood and minor adjustments were made. The average length of the interviews was 26 minutes. In addition to the interviews, a form was used to characterize the demographics and jobs of the participants.

The data from the interview transcripts was analyzed using the Content Analysis framework in the thematic modality, respecting the three phases proposed: pre-analysis, exploration of the material, and data processing²⁰. In the first phase, the material was read exhaustively for appropriation purposes. The thematic categories representing the data collected were defined in the second stage. The third stage involved interpreting the results.

This study is part of a matrix research project, which has been approved by the ethics committee under opinion no. 4.932.314. To preserve the confidentiality of the respondents, the letter “E” was coded, followed by the sequential number of interviews.

RESULTS

Table 1 shows the socio-occupational characterization of the professionals (n=10) who took part in the survey.

Table 1
Socio-occupational characterization of the study participants. Porto Alegre (RS), Brazil, 2023.

Professional category	Sex	Age (years-old)	Length of time at the institution (years)	Time spent working with elements related to Hospital Accreditation (years)
Administrator	Female	46	13	5
Nurse	Female	60	34	22
Nurse	Female	44	19	13
Nurse	Female	44	17	9
Nurse	Female	46	22	5
Nurse	Female	59	31	10
Medical	Male	40	10	10
Medical	Female	56	16	13
Medical	Female	40	11	9
Pharmacist	Female	49	23	10

• Source: Prepared by the authors (2023).

After coding and analyzing the data, three thematic categories emerged, compiling leaders’ perspectives on resuming the Hospital Accreditation process in a “post-pandemic” context of COVID-19.

Table 2
Summary of the thematic categories and their respective nuclei of meaning. Porto Alegre (RS), Brazil, 2023.

Thematic Category	Cores of Meaning
Hospital changes and strategies demanded by the COVID-19 pandemic	Review of protocols
	Dissemination strategies
	Structural changes
Challenges of managing quality of care and patient safety in the context of the pandemic	Adversities faced in resuming accreditation.
	Weaknesses in the work process
	Lessons learned from the pandemic
Managing the resumption of the Hospital Accreditation process after the pandemic	Organizational climate and team engagement
	The role of leadership in restoring accreditation

• Source: Prepared by the authors (2023).

With the COVID-19 pandemic, contingency strategies had to be developed to deal with the health situation. An example of this was the need to review protocols driven by accreditation.

[...] the documents [...] I reviewed each one and checked that what is written is actually done in practice because that is what the evaluators will be doing. (E1)

[...] it started in 2021, with the resumption of Equalization, our ongoing quality of care program [...]. All our medical records are now computerized. (E3)

Below are the fragments that point to the difficulties identified by the interviewees when reviewing protocols and routines.

[...] pharmacy accreditation has many more new processes that we must implement than processes that need to be resumed, or that we had lost from previous years. (E2)

[...] we realized that a lot of records are missing. The hospital has done many good things in recent years, but we have nothing in writing, nothing to prove it, and we need evidence for accreditation. (E4)

[...] we are having to do this readjustment, to look again at the normal things of infection control and adapting them. (E10)

The researched institution developed multimodal information dissemination strategies during the pre-accreditation period. Therefore, this content is thematic category 1, core meaning “Dissemination strategies”.

[...] multimodal strategies, right [...]. The executive, medical, nursing, and administrative boards have mobilized for this to make this capillarization happen. (E3)

The most frequently mentioned services were communication, nursing education, and the spaces proposed by the board. Regarding the strategies adopted by the institution’s communication service:

[...] the hospital’s SECOM [Communication Service] has been a great partner in creating something a little more playful, more fun, that generates greater engagement. (E4)

[...] each piece of content on the hotsite and in the publicity campaign is handled differently, not least because they are for different audiences. (E5)

Concerning the strategies adopted by the nursing education service, the following statements stood out:

[...] distance learning resources, people have access to courses. (E8)

[...] the strategies that SEDE [Nursing Education Service] used were conversation circles in the units, face-to-face and [Google] Meet training for the teams, [...] also the publication of a manual of questions and answers to all the questions that can be asked with the answers so that the professionals can remember. (E9)

The institution went through a process of expanding its physical area during the pandemic. It was a planned action, before COVID-19, however, this moment accelerated the occupation of these spaces, as the following reports show, arranged in thematic category 1, core meaning “Structural changes”.

[...] every new area that we open in the hospital has to be planned, approved by the government, hired, trained in the right period, the person is gradually integrated into the teams, and during the pandemic, we had to do all this on an emergency basis. (E5)

[...] it was all urgent, like when you move house, and you don’t have a sofa or a TV, you go and find a way to survive. (E9)

One of the interviewees also mentioned the obstacles imposed by this expansion process.

[...] we went from a hospital that had one block to a hospital that now has three blocks. [...] so even though it’s an improvement, it’s weakened [...] the way it used to be from one floor to the next if you went up the stairs, you could talk to your colleague to find out where the material was, today you have a distance of kilometers [...] the transportation of patients today is more fragile because of this distance. [...] we didn’t increase staff, human resources, we didn’t increase material resources, we only increased the physical area. (E3)

In thematic category 2: “Challenges in managing quality of care and patient safety arising from the pandemic context”, grouped perceptions related to the difficulties experienced “post-pandemic” in controlling internal processes in the most different management segments, including human resources management, and how these impacted on the resumption of Hospital Accreditation. Below are the fragments of the core meaning, “Adversities faced in resuming accreditation”.

[...] a lot of new people at the hospital, with some retirements during this period, so it was really a much more intense process to remind all the teams of how we did things, what the process was like, what the standards were. (E6)

[...] the hospital today has a very large number of new professionals who don’t know about accreditation, who don’t know our routines, who don’t know or know little about our care processes. (E9)

According to the leaders, a short period was spent implementing continuous improvement processes and improving the quality of care, focusing on the good practices essential for accreditation.

[...] we had little time to engage the teams again. (E3)

[...] so we often have to do it, and there’s very little time, and we have to train a very large number of professionals. (E7)

On the other hand, during the pandemic, the focus was not on following up the preparatory actions for accreditation, since the objective at that time was to tackle COVID-19, as listed in fragments of the core meaning: “Weaknesses in the work process”.

[...] we couldn’t continue with the meetings and everything, but some things had already been implemented and aligned with the previous accreditation. (E1)

[...] we suspended distance learning courses, meetings, focus groups, we suspended everything, right, we didn’t, we only focused on the health of professionals, on protecting themselves. (E3)

The leaders recognized that some care processes and practices aimed at patient safety during the pandemic were left in the background, to the detriment of the scenario.

[...] during COVID, let’s think that we lowered, reduced some quality standards, because at that time the risk-benefit balance seemed much better by removing those factors. (E4)

[...] getting people to remember the safety culture again, because this was lost a lot during the pandemic and no longer had a focus. (E10)

Related to this issue, one participant said there had been an increase in adverse events compared to the years before the pandemic.

[...] we see a lot of adverse events happening when we compare them with other years, years before the pandemic, they had a significant increase. (E9)

Faced with the day-to-day challenges imposed by the pandemic, the interviewees mentioned in their speeches the need to establish a differentiated outlook as a learning experience to be better prepared to deal with health crises. This is evident in the fragments of the core meaning: “Lessons learned from the pandemic,” set out below.

[...] we have to have adaptable systems, because there may be new crises and we’ll have to adapt again, so we must keep learning how to adapt to situations, including structures. (E4)

[...] learning is perhaps being able to better define contingencies . [...] the pandemic has also brought this spirit of collaboration and institutional adaptation to difficulties. (E5)

Despite the challenges, lessons learned, such as the one provided by the interviewee below, indicate that the management processes have been redesigned and have proved effective.

[...] we could share experiences that previously only happened in one area, and share them with several others. [...] it was very interesting to observe that processes only happen in one area that could be shared with another. (E9)

This category addressed the participants’ perceptions of the organizational climate, team engagement, and the role of leadership in regaining accreditation. Health professionals have dedicated themselves to dealing with the pandemic and, after the greatest crisis, there are still repercussions in preparing for the resumption of Hospital Accreditation. The leaders’ speeches show that post-pandemic fatigue is a challenge to manage in order to engage the teams, and these are grouped together in thematic category 3: “Managing the resumption of the Hospital Accreditation process after the pandemic”. Below are some fragments of the core meaning: “Organizational climate and team engagement”.

[...] I think we’re having some difficulties because the groups are exhausted. [...] we feel as if they’re going through a hangover after everything we’ve experienced in these two years of the pandemic. (E2)

[...] this resumption, to give the team a boost for accreditation, is being much more careful because we know that our professionals are under a lot of emotional strain, and we haven’t had time to recover our emotional state post-pandemic. (E3)

In view of this atypical scenario for this preparation in search of the accreditation seal, it was evident from the speeches of the leaders that there was a need to guarantee listening spaces with the teams. Thus, the core of meaning emerged: “The role of leadership in resuming accreditation”.

[...] the leadership is the one who sets the tone, sets the tone of that team, and who will take the information to the team in a generous, loving way, in a filtered way, and even see the possibilities of how we can improve the processes. And then he will also be able to listen to this team. (E3)

[...] the role of leadership is fundamental, it’s for you to call, it’s for you to listen because people have their complaints and they are legitimate [...] it’s for you to welcome this person and try to make them see the good side. (E9)

It was possible to identify the leader’s importance in directing the team to achieve the expected results and in transmitting information so that employees could identify the institutional purpose.

[...] as a leader, I have to help her see the purpose, the motivation and that together we’ll be able to get out of this moment that isn’t so good. (E9)

DISCUSSION

One of accreditation’s basic objectives is to review protocols and routines in the institutions that adhere to it⁶. In line with this, the interviewees mentioned that the institution in question already carried out actions to this end, including having its ongoing program, called “eQUALISação”, to monitor the quality of care.

The logic of continuous improvement assumes the need to review processes and quality parameters based on the new edition of the JCI manual¹⁷. In the context of the pharmacy service, the interviewee pointed out that the need for new processes was more significant than the need for routines that were not being followed. He pointed out that the services even needed to analyze whether what was being requested was feasible, considering the institution’s context at the time. If not, alternatives would have to be considered. As has already been seen in another study, the process benchmarks proposed by the JCI can sometimes not be identified by some category as adequate, or even with little basis⁹, for the reality of the country/institution in which the evaluation is being carried out⁷, which is why the vision of leaders and those who carry out the care work is so important in defining strategies for achieving the desired standards of excellence.

Still on the subject of the difficulties pointed out, a barrier was identified related to records, in which it was mentioned that there was a mismatch between the work carried out and what was documented. That said, the role of nursing is extremely important if the practices proposed by accreditation are to be truly adopted by professionals, and if teams are to understand the importance of these processes for their safety and that of the patient¹⁰.

Leadership is seen as a skill that makes it possible to influence other people and improve the relationship between the leader and the person being led, which can result in better performance and greater productivity²¹. Based on this premise and the post-pandemic scenario, leadership is understood to be one of the most influential factors in shaping a culture of quality and safety in healthcare²².

The research described here corroborates the context previously described in the literature about interrupting some hospital activities. With the pandemic, some processes, such as hospital infection control and quality of care management, were restricted and remodeled for the health crisis^14,23.

In the organization surveyed, nursing education and communication services proved extremely important for disseminating information related to the accreditation process. According to a study in a hospital in Israel, with multi-professional and intersectoral involvement, it is possible to reduce resistance and consequently increase employee engagement, which is a challenging point when adhering to Hospital Accreditation ⁷.

Some change processes, such as external certification, can be met with resistance from some professionals. However, organizational change needs tools to reduce resistance, and, in this sense, the involvement of leaders is essential²⁴. In the case studied, the relationship between the teams’ tiredness/exhaustion is a major challenge for leaders in giving meaning to the process of quality certification by the care base.

Despite these challenges, it was pointed out that accreditation would help the institution to improve services in these new areas and standardize them, with the development of teams and with actions that were impossible to carry out in the context of the pandemic. Nursing professionals’ satisfaction and positive perception of the Hospital Accreditation process have already been described in the literature¹². In addition, the process strengthens the public’s view of and trust in the institution and, at the same time, the view of its employees⁸.

Coping with the COVID-19 pandemic has been fraught with unprecedented challenges and has required the structuring of effective management practices and policies capable of providing the conditions for healthcare in hospital settings²⁵. Accreditation is identified as a driving force behind necessary actions, but it is sometimes put on the back burner⁸. There is evidence of a relationship between the level of certification and the points improved²⁶. A study in Dubai suggested that performance measures be developed to assess this impact, thus providing a more objective measurement²⁷.

In the post-pandemic scenario, there has been a need to resume processes previously left in the background. For these processes to be successful, there needs to be a good relationship between the leaders and the people they lead so the information can be properly disseminated. A study carried out in 11 hospitals in the state of São Paulo showed that authentic leadership was positive in the context of Hospital Accreditation to establish a healthy, transparent, responsible, and ethical working environment, showing a correlation between the evaluation of those led about their leaders and their satisfaction with their work²⁸.

One participant said there was a perception of an increase in adverse events in the period following the pandemic. Associated with this, it should be emphasized that the existing work processes in organizations need to be linked to the objectives of patient safety, which requires the collaboration and participation of all professionals in adhering to notifications, and that discussions about the incident are strategies for prevention and team learning²⁹.

A study carried out in Saudi Arabia found that the effectiveness of integrating accreditation standards depends heavily on making sense of accreditation and understanding the mechanisms by which standards are routinized into operations. The study indicates that the phases of standards integration are sequential, interconnected, and influenced by organizational culture, teamwork, and leadership engagement³⁰.

One limitation of this research was that the interviews were not returned to the participants for validation. However, by understanding the concerns, challenges, and opportunities perceived by leaders, the research nevertheless has the potential to offer contributions to hospital management, helping to adapt the processes and practices related to the recertification process after a global health crisis.

Hospital Accreditation is intrinsically linked to quality and patient safety, and the study strengthens the assumption that this is also inseparable from the engagement of leaders, who will influence people to adhere to the demanding requirements of accreditation. It is therefore hoped that the results of this study will facilitate the resumption and/or start of the accreditation process for hospital institutions.

FINAL CONSIDERATIONS

For the strategic leaders, resuming Hospital Accreditation in the “post-pandemic” context was highly challenging and, at the same time, opportune to rescue the processes previously consolidated in the institution for quality management and patient safety, but which were weakened or even lost in the face of the COVID-19 pandemic.

The leaders reported adversities stemming from the administration of human resources and time management, reflecting the pandemic context that exhausted the health services. However, lessons were learned in terms of communication processes and nursing education among employees so that institutional processes could be resumed and disseminated according to the recommended quality standards. In this sense, the leadership recognized the teams’ exhaustion and worked to motivate people and spread the information necessary for the success of the quality certification.

ACKNOWLEDGMENTS

“This study was carried out with funding from the Institutional Scholarship Program for Scientific Initiation (No. 0780451) of the Hospital de Clínicas de Porto Alegre, with resources coming from the institution itself.”

• HOW TO REFERENCE THIS ARTICLE:
  Treib JN, Rodrigues NH, Barbosa A da S, Guardalupe JA, Magalhães AMM de, Oliveira JLC de. Resumption of hospital accreditation in the ‘post-COVID-19 pandemic’ era: leadership perspectives. Cogitare Enferm. [Internet]. 2024 [cited “insert year, month and day”]; 29. Available from: https://doi.org/10.1590/ce.v29i0.95635.

References

• ¹ Pinto BALC, Serpa ALO, Paula JJ de, Costa DS, Robis K, Diaz AP, et al. Increased risk of health professionals to feel traumatized during the COVID-19 pandemic. Sci. Rep. [Internet]. 2021 [cited 2023 Aug. 14]; 11:18286. Available from: https://doi.org/10.1038/s41598-021-97783-6
  » https://doi.org/10.1038/s41598-021-97783-6
• ² Yıldırım M, Arslan G, Özaslan A. Perceived risk and mental health problems among healthcare professionals during COVID-19 pandemic: exploring the mediating effects of resilience and Coronavirus fear. Int. J. Ment. Health. Addict. [Internet]. 2022 [cited 2023 Aug. 14]; 20(2):1035-45. Available from: https://pubmed.ncbi.nlm.nih.gov/33223977/
  » https://pubmed.ncbi.nlm.nih.gov/33223977
• ³ Kantorski LP, Oliveira MM de, Treichel CA dos S, Bakolis I, Alves PF, Coimbra VCC, et al. Mental health of nursing professionals during the COVID-19 pandemic: a cross-sectional study. Rev. Saúde Pública. [Internet]. 2022 [cited 2023 Aug. 14]; 56:8. Available from: https://doi.org/10.11606/s1518-8787.2022056004122
  » https://doi.org/10.11606/s1518-8787.2022056004122
• ⁴ Gleriano JS, Fabro GCR, Tomaz WB, Goulart BF, Chaves LDP. Reflections on the management of Brazilian Unified Health System for the coordination in facing COVID-19. Esc. Anna Nery. [Internet]. 2020 [cited 2023 Aug. 14]; 24(spe):e20200188. Available from: https://doi.org/10.1590/2177-9465-EAN-2020-0188
  » https://doi.org/10.1590/2177-9465-EAN-2020-0188
• ⁵ Santos MA dos, Landim ELAS, Farias TS de. Health planning in the context of the covid-19 pandemic, Bahia, Brazil. Rev. Baiana Saúde Pública. [Internet]. 2021 [cited 2023 Aug. 14]; 45(2n.esp):80-91. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1342816
  » https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1342816
• ⁶ Organização Nacional de Acreditação (ONA). O que é acreditação [Internet]. 2023 [cited 2023 Aug. 14]. Available from: https://www.ona.org.br/acreditacao/o-que-e-acreditacao
  » https://www.ona.org.br/acreditacao/o-que-e-acreditacao
• ⁷ Bord S, Sass I, Hayms G, Moskowitz K, Baruch H, Basis F. Involvement and skepticism towards the JCI Accreditation process among hospital’s four sectors employees: suggestions for cultural change. Isr. J. Health Policy Res. [Internet]. 2021 [cited 2023 Aug. 14]; 10:74. Available from: https://doi.org/10.1186/s13584-021-00507-4
  » https://doi.org/10.1186/s13584-021-00507-4
• ⁸ Lewis K, Hinchcliff R. Hospital accreditation: an umbrella review. Int J Qual Health C. [Internet]. 2023 [cited 2023 Aug. 14]; 35(1):1-7. Available from: https://doi.org/10.1093/intqhc/mzad007
  » https://doi.org/10.1093/intqhc/mzad007
• ⁹ Ibrahim SA, Reynolds KA, Poon E, Alam M. The evidence base for US joint commission hospital accreditation standards: cross sectional study. BMJ. [Internet]. 2022 [cited 2023 Aug. 14]; 377:e063064. Available from: https://doi.org/10.1136/bmj-2020-063064
  » https://doi.org/10.1136/bmj-2020-063064
• ¹⁰ Possa DC, Marchi KCDS de, Tolotti NGR, Griep R. Accreditation in the hospital surgical field: a qualitative approach of its impacts. Thêma Sci. (Online). [Internet]. 2021 [cited 2023 Aug. 14]; 11(1):211-22. Available from: https://ojsrevistas.fag.edu.br/index.php/RTES/article/view/1260
  » https://ojsrevistas.fag.edu.br/index.php/RTES/article/view/1260
• ¹¹ Devkaran S, O’Farrell PN, Ellahham S, Arcangel R. Impact of repeated hospital accreditation surveys on quality and reliability, an 8-year interrupted time series analysis. BMJ Open. [Internet]. 2019 [cited 2023 Aug. 14]; 9:e024514. Available from: https://doi.org/10.1136/bmjopen-2018-024514
  » https://doi.org/10.1136/bmjopen-2018-024514
• ¹² Oliveira JLC de, Magalhães AMM de, Bernardes A, Haddad M do CFL, Wolff LDG, Marcon SS, et al. Influence of hospital accreditation on professional satisfaction of the nursing team: mixed method study. Rev. Latino-Am. Enfermagem. [Internet]. 2019 [cited 2023 Aug. 14]; 27:e3109. Available from: https://doi.org/10.1590/1518-8345.2799.3109
  » https://doi.org/10.1590/1518-8345.2799.3109
• ¹³ Dutra HS, Guirardello EDB. Nursing work environment and accreditation: Is there a relationship? J. Nurs. Manag. [Internet]. 2021 [cited 2023 Aug. 14]; 29:2183-88. Available from: https://doi.org/10.1111/jonm.13371
  » https://doi.org/10.1111/jonm.13371
• ¹⁴ Lima KJV, Lacerda MVGD, Monteiro WF, Ferreira DS, Andrade LLCD, Ramos FRS. Technical-assistance arrangements in coping with the COVID-19 pandemic from the managers’ perspective. Rev. Latino-Am. Enfermagem. [Internet]. 2022 [cited 2023 Aug. 14]; 30:e3539. Available from: https://doi.org/10.1590/1518-8345.5799.3539
  » https://doi.org/10.1590/1518-8345.5799.3539
• ¹⁵ Yin RK. Estudo de caso: planejamento e métodos. 5th ed. Porto Alegre: Bookman; 2014. 320 p.
• ¹⁶ Souza VRS, Marziale MHP, Silva GTR, Nascimento PL. Translation and validation into Brazilian Portuguese and assessment of the COREQ checklist. Acta Paul Enferm. [Internet]. 2021 [cited 2024 Mar. 26]; 34:eAPE02631. Available from: http://dx.doi.org/10.37689/acta-ape/2021AO02631
  » http://dx.doi.org/10.37689/acta-ape/2021AO02631
• ¹⁷ Vinuto J. Snowball sampling in qualitative research: an open debate. UNICAMP. [Internet]. 2014 [cited 2023 Aug. 14]; 22(44):203-20. Available from: https://doi.org/10.20396/tematicas.v22i44.10977
  » https://doi.org/10.20396/tematicas.v22i44.10977
• ¹⁸ Fontanella BJB, Ricas J, Turato ER. Saturation sampling in qualitative health research: theoretical contributions. Cad Saúde Pública. [Internet]. 2008. [cited 2024 Mar. 26]; 24(1):17-27. Available from: https://doi.org/10.1590/S0102-311X2008000100003
  » https://doi.org/10.1590/S0102-311X2008000100003
• ¹⁹ Joint Commission International Accreditation. Standards for Hospitals. 7th. 2020. 424 p.
• ²⁰ Bardin L. Análise de conteúdo. [Internet]. Lisboa: Edições 70; 2016 [cited 2023 Aug. 14]. Available from: https://madmunifacs.files.wordpress.com/2016/08/anc3a1lise-de-contec3bado-laurence-bardin.pdf
  » https://madmunifacs.files.wordpress.com/2016/08/anc3a1lise-de-contec3bado-laurence-bardin.pdf
• ²¹ Mondini CC da SD, Cunha ICKO, Trettene A dos S, Fontes CMB, Bachega MI, Cintra FMR. Authentic leadership among nursing professionals: knowledge and profile. Rev. Bras. Enferm. [Internet]. 2020 [cited 2023 Aug. 14]; 73(4):e20180888. Available from: https://doi.org/10.1590/0034-7167-2018-0888
  » https://doi.org/10.1590/0034-7167-2018-0888
• ²² Abelha DM, Carneiro PC da C, Cavazotte F de SCN. Transformational leadership and job satisfaction: assessing the influence of organizational contextual factors and individual characteristics. Rev. Bus. Manag. [Internet]. 2018 [cited 2023 Aug. 14]; 20(4):516-32. Available from: https://doi.org/10.7819/rbgn.v0i0.3949
  » https://doi.org/10.7819/rbgn.v0i0.3949
• ²³ Oliveira EC da S, Silva FP da, Pereira EBF e, Oliveira RC de. Actions of the hospital infection control committee in front of the new coronavirus. Rev. Baiana Enferm. [Internet]. 2020 [cited 2023 Aug. 14]; 34:e37259. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1137051
  » https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1137051
• ²⁴ Caram CS, Brito MJM, Peter E. Hospital accreditation: excellence as a source of moral distress for nurses. Enferm. Foco. [Internet]. 2019 [cited 2023 Aug. 14]; 1(1):31-35. Available from: http://revista.cofen.gov.br/index.php/enfermagem/article/view/1868/423
  » http://revista.cofen.gov.br/index.php/enfermagem/article/view/1868/423
• ²⁵ Santos JL dos, Lanzoni GM de M, Costa MFBNA da, Debetio JO, Sousa LP de, Santos LS dos, et al. How are university hospitals coping with the COVID-19 pandemic in Brazil? Acta Paul. Enferm. [Internet]. 2020 [cited 2023 Aug. 14]; 33:eAPE20200175. Available from: https://doi.org/10.37689/acta-ape/2020AO01755
  » https://doi.org/10.37689/acta-ape/2020AO01755
• ²⁶ Pasinringi SA, Rivai F, Arifah N, Rezeki SF. The relationship between service quality perceptions and the level of hospital accreditation. Gac. Sanit. [Internet]. 2021 [cited 2023 Aug. 14]; 35(S2):S116-S119. Available from: https://doi.org/10.1016/j.gaceta.2021.10.009
  » https://doi.org/10.1016/j.gaceta.2021.10.009
• ²⁷ Al-Alawy K, Moonesar IA, Obaid HAM, Bawadi EIA, Gaafar R. Hospital accreditation: a review of evidence, regulatory compliance, and healthcare outcome measures. Dubai Med. J. [Internet]. 2021 [cited 2023 Aug. 14]; 4(3)248-55. Available from: https://doi.org/10.1159/000516483
  » https://doi.org/10.1159/000516483
• ²⁸ Batista SA, Miclos PV, Amendola F, Bernardes A, Mohallem AG da C. Authentic leadership, nurse job satisfaction and hospital accreditation: a study in a private hospital network. Rev. Bras. Enferm. [Internet]. 2021 [cited 2023 Aug. 14]; 74(2):e20200227. Available from: https://doi.org/10.1590/0034-7167-2020-0227
  » https://doi.org/10.1590/0034-7167-2020-0227
• ²⁹ Moreira IA, Bezerra ALQ, Teixeira CC, Braga Q de P, Costa A de A, Rocha JP. Nurses’ perception of incident reporting to promote hospital patient safety. Enferm. Foco. [Internet]. 2021 [cited 2023 Aug. 14]; 12(5). Available from: https://doi.org/10.21675/2357-707X.2021.v12.n5.4345
  » https://doi.org/10.21675/2357-707X.2021.v12.n5.4345
• ³⁰ Algunmeeyn A, Alrawashdeh M, Alhabashneh H. Benefits of applying for hospital accreditation: The perspective of staff. J. Nurs. Manag. [Internet]. 2020 [cited 2023 Aug. 14]; 28:1233-40. Available from: https://doi.org/10.1111/jonm.13066
  » https://doi.org/10.1111/jonm.13066

Edited by

• Associate editor:
  Dra. Cremilde Radovanovic

Publication Dates

• Publication in this collection
  20 Sept 2024
• Date of issue
  2024

History

• Received
  14 Aug 2023
• Accepted
  28 Apr 2024