This article deals with the development of a self-evaluation model of quality management, with a focus on people management standards in the hospital. Initially a research was carried out in order to identify the main ideas and characteristics of the studies related to the evaluation of the quality of health services, with greater emphasis on hospital accreditation, as well as a comparison between the accreditation methodologies ONA and JCI/CBA. Through a case study of exploratory nature and the application of a questionnaire to hospital managers of a university hospital, it was possible to assess the adequacy of standards that would compose the final model of self-assessment - the final product of this research. The results showed that participants managers understand the importance of setting standards to support the management and monitoring of the institution with a view to the evolution and continuous improvement.
Key-words: Hospital Management, Quality Standards, People Management.
In a scenario of constant change, where large companies operate in a quality management context, the organizations of worldwide health care are embedded in a dynamic market in which answers are required to seek maximize some issues, such as security awareness, evaluation of the quality of patient care and, especially, greater professionalization of hospital management.
The implementation of a quality culture can arise within an organization when internal teams are formed and become responsible for planning and monitoring standards and indicators, with defined and structured objectives, in pursuit of compliance and constant improvement. This leads to a self-evaluation process, i.e. an internal assessment to identify points for improving the performance of the organization.
The evaluation can also occur an external way, or by third parties, as in the case of hospital accreditation, which has the objective of verifying whether a hospital meets a series of pre-established standards.
Currently, the main organization responsible for national accreditation is the National Accreditation Organization (ONA-from the portuguese Organização Nacional de Acreditação), which follows the methodology contained in the Brazilian Manual of Accreditation: Health Service Provider Organizations The manual, as the accreditation standards of the Joint Commission International (JCI) for Hospitals, is represented in Brazil by the Brazilian Accreditation Consortium (CBA-from the portuguese Consórcio Brasileiro de Acreditação) (Seabra, 2007).
Both in the national model manual of accreditation and the international are found various requirements centered on the patient and the administration of the institution, among other categories, including patient safety goals, medication management, infection control, corporate governance and leadership, management communication and information, which generally correspond to specific services or organizational structures of hospitals.
These manuals also address aspects related to people management standards most connected to the planning process, orientation and education that address the needs inherent to hospitals in relation to the various professionals involved, their competency profiles and their specialties and qualifications.
However, despite the importance of evaluations, internal or external, for the development of services provided by hospitals, it appears that many of them fail to implement a model that fits your needs, whether on procedural or financial reasons. In this sense, in order to enhance the development of an internal evaluation model, this study suggests the construction of a model of self-assessment based on methodological standards of accreditation of ONA and JCI/CBA, with focus in people management.
It is understood that the practice of internal evaluation, as well as stimulating an awareness strategy of the institution's professionals on the importance of quality improvement in work processes, could also minimize or even eliminate the high costs involved in obtaining the accreditation, as payment due to accreditation bodies, one of the main barriers that hinder the process of accreditation of smaller hospitals.
In addition, it is believed that an evaluation of institutional resources procedure, periodically, voluntary and mainly focused on continuing education of professionals, can generate a commitment to improve process, quality, safety and reduction of environmental risks, for both patients and other professionals involved.
Avedis Donabedian was a pioneer on the study about quality assessment in health services and his contribuition are so important that even today are used as the classic triad – structure, process and outcome (Donabedian, 1966). On this triad the structure is connected to the institutions organization and the caracteristics of its human, physical and financial resources. The processes correspond to the content of the service and how it is executed, and the results represent the impact achieved with the service, in terms of improvement in health and well-being of individuals, groups or population, as well as user satisfaction for services.
This author realized that previous studies considered only the industrial model and dedicated to the field of health care and medical care. Novaes (2000) mentions that Donabedian (1990) suggests a new concept, called seven pilars of quality:
• Acceptabillity – global service accordance with the wishes and expectations of patients and their families;
• Effectiveness - maximum degree of health improvement that can be achieved with the best available care;
• Efficiency - propensity of science and art of health care, able to offer positive advances to well-being of patients
• Efficiency - ability to reduce the most of the care costs without reducing significantly the health improvement level;
• Equity - compliance with the principles governing the fair distribution of tasks related to health care and its benefits among all members of the population;
• Legitimacy - compliance with ethical principles, values, rules, regulations and laws governing the community;
• Optimization - balance between the costs and benefits of health care. Another important scholar of quality in health services is Donald Berwick. As quoted by Malik et Schiesari (2002), the involvement of this author started from the 1980s, particularly with the National Demonstration Plan (NDP), which contributed to greater approximation of professionals, models and tools of quality management in the segments industrial and business, in general with the hospital and American health professionals. The learning from the NDP, among other contributions, it was summed up in ten topics relevant to improving the quality (Berwick et al., 1994):
• The possibility of applying tools and quality improvement tools in health care;
• The importance of cross-functional teams to improve processes in the hospital;
• The ease and the large amount of useful data for improving quality in health care;
• quality improvement methods in health care are well received by the professionals involved, especially in nursing;
• The notion that the poor generates high costs, about 40% or 50% of the total cost of hospitals, and that improved processes can reduce them;
• Search for alternatives to supply a greater difficulty in engaging physicians; • Understanding the need for training for all professionals;
• Alignment that improving quality should also occur in non-clinical processes;
• Perception that health institutions may need a broader definition of quality;
• Clarity that in the same way as in industry, the largest responsibility of quality improvement is in the hands of leaders.
Schiesari (2014) presents a study on the contributions of the various quality management models applied in hospitals or health care in general. In Brazil, there are few hospitals that have some type of quality management model applied, but it is unquestionable that most of the leaders of these hospitals already have knowledge about these models. The author mentions some of the positive and negative results that come with the application of quality management models in health:
• Improved management: concepts such as strategic planning, quantitative data analysis and use of indicators to support decision making are examples of more precise instruments that can be introduced with the implementation of quality management models.
• Standardization of processes: with the possibility of use of rules, regulations, procedures, protocols or clinical itineraries previously prepared in order to make more homogeneous working practices, providers institutions of health care have the opportunity to explain the results expected to considered critical processes, and can minimize the variation of clinical and administrative practices related.
• Staff training: the aspect of competence development is considered critical to the successful implementation of quality model. In this way, the hospitals involved seek constant planning and control of the training of its professionals, offering the development and training courses.
• Teamwork: the proper functioning of multidisciplinary and interdisciplinary team around the patient care is a constant concern. Apparently, it remains a major challenge and sometimes a dream. These initiatives have the merit of raising awareness often the institutions and their leaders to the importance of the theme.
• Care focuses on the patient: in these models, patients are the main focus of management. It is essential to pay attention to their expectations and needs, and make them active actors in the decision-making process. The measurement of patient satisfaction should be an important aspect.
• Motivation: the quest for improved quality can motivate employees at an early time. However, it is common that in the long run a lack of motivation occurs by the difficulty of maintaining quality model.
• External recognition: the accreditation or certification can bring better results regarding the evaluation of its customers by offering a competitive edge and enabling participation in financing conditioned to certain achievements.
• Culture Change: is not a very simple task, however, especially in its initial phase, the institutions realize a positive change in people's behavior and that many processes have been modified.
• Discontinuity: the professionals involved can not keep the same standards and end up discouraged and not believing more on the positive side of quality.
• Bureaucratization: with demotivation of professionals, we highlight the aspects that, when excessive, become negative - standardization, procedures, measures, documents, etc.
• Low creativity: in many cases, due to the low autonomy in the activities, there is no place to encourage other initiatives and innovative ideas.
• Generalization: models can not be adapted to local realities and organizational culture.
The discussions about the assessment of the quality of services and the health system occur a long time, yet structured and systematic evaluation models began to be practiced more recently. According to Fortes (2013), review is to make value judgments about the qualities, attributes, or properties of an object, an action, an idea, a person, etc.
The specific models that assess the quality of health services have developed as a way of adapting that already existed. Among some of the most prominent, there is the Deming Prize, Malcolm Baldrige the prize, the European Foundation for Quality Management (EFQM), the National Quality Award (PNQ) and ISO standards.
Valuation models have a number of standards, tools and indicators that guide the quality management practices within organizations.
Assessments can be internal or external. External are generally carried out by third parties; and internal, implemented by members of the organization itself.
Common way, external evaluations are carried out by specialized organizations that verify the fulfillment of pre-established standards. In the specific case of health institutions, the external evaluation system is called hospital accreditation.
The hospital accreditation refers to external evaluation of a health institution, held by an entity, usually non-governmental, separate and independent, in order to determine whether the hospital analyzed answers to a series of standards. In most cases, accreditation is voluntary and generates a commitment to improvement of process, quality, safety and reduction of environmental risks, patients and professionals involved (JCI, 2013).
Currently, many countries use and develop accreditation methods. In Brazil, since the 1990s, are developed quality control models in health care, with several investments that seek to systematize standards compliance and quality levels control instruments (ONA, 2010). Although they are few, hospitals accredited in Brazil can achieve satisfactory results when they apply the recommended standards in the accreditation models.
According Seabra (2007), the accreditation models most used in Brazil are international model by JCI/CBA and the national model by ONA. In a survey conducted by the month of March 2016, the providers of health care institutions accredited by JCI/CBA in Brazil accounted for a total of 63 (CBA, 2016); already ONA, through its accrediting organizations, believed 505 institutions (ONA, 2016).
JCI is an international division of Joint American Commission and is represented in Brazil by the Brazilian Accreditation Consortium (CBA). Institutions seeking accreditation grant from JCI/CBA undergo an educational process where the internal members are trained in order to adapt existing practices to the standards established by the manual. Subsequently, the institution is evaluated by the team of experts of the accreditation entity. May arise two results in this process: the organization is accredited or not, with no grade levels in the granting of accreditation (Fortes, 2013).
AONA uses an accreditation methodology that can be offered to various services, such as hospital services, outpatient, therapeutic and emergency care, laboratory, among others. In this model, institutions can be accredited on 3 different levels of complexity.
At level 1 accreditation, the basic quality requirements must be met, requiring skilled human resources for each institutional area of operation. At level 2, full accreditation, the focus is greater in planning the organization of care, with greater control of aspects related to documentation, training, statistical subsidies of support for the management and clinical decision making process, besides implementation of internal audit procedures. At level 3 accreditation with excellence, there is objective evidence of institutional policy of continuous improvement, as structure, new technologies and technical and professional update. (ONA, 2010).
Malik et Schiesari (2002) estabilishes a comparison between ONA and JCI/CBA models, as shown below in figure 1.
Figure 1. Comparison between the national model ONA and international JCI / CBA.
Source: Elaborated based on Malik et Schiesari (2002)
Duarte et Silvino (2012) highlight the following positive aspects to the implementation of an accreditation model: reliability, which can be built during the accreditation process with a new organizational culture; increase the level of satisfaction of patients; increase in efficiency and care to people greater community confidence in the quality of service.
According Rothbarth (2011), some barriers that may arise in the accreditation process are the little support from the top management of the hospital, resistant culture to change, the degree of complexity of the hospital, the lack of involvement and commitment of the professionals, the difficulties of understanding and misinterpretations, expectations for immediate results, the organization chart and the current management model, and the low use of indicators.
Manzo et al. (2012) state that health professionals do not have a uniform view about the accreditation process, and some have greater awareness about the positive aspects, and others about the negative aspects Manzo et al. (2012) state that health professionals do not have a uniform view about the accreditation process, and some have greater awareness about the positive aspects, and others about the negative aspects.
In order to establish criteria for comparison between the accreditation models ONA and JCI / CBA, it is necessary to understand the role and constitution of the people management area in organizations.
As stated by Gil (2006), the people management area must contribute to organizations to be effective through the individuals. Thus, it is important to understand the function of each subsystem that make up this area to enable an integrated way performance, since each of them can influence the other, positively or negatively. Below are listed the subsystems of people management (Gil, 2006):
• Add people – It includes all activities that permeate the attraction and selection of people, as well as integrating new employees.
• Apply people - refers to the mapping of activities, analysis and job descriptions. It also covers the career plan, performance evaluation and dissemination of organizational culture.
• Rewarding people - regard to remuneration and recognition on the basis of deliveries made.
• Develop people - responsible for training and professional development, encompassing the needs assessment, implementation of development programs, change management programs and internal communications.
• Keep people - creates conditions for maintaining climate and organizational culture, including health management, occupational safety, hygiene and quality of life.
• Monitor people - Refers to monitoring and management of people through the verification of results.
Both accreditation models surveyed in this study have credibility and qualifications to evaluate hospitals. However, there are some differences between them with respect to the standards set for evaluation. The comparative referring to people management standards is signaled in Figure 2.
Figure 2. Comparison between the national model ONA and international JCI/CBA with an emphasis on people management.
Source: Own elaboration.
The comparison between the models ONA and JCI/CBA was structured with bigger foccus on its characteristics, since it showed a little perceptible the aspects that could be considered disadvantages and/or advantages. Besides that, some positive and/or negatives aspects of the models was identified, namely:
• The standards level of detail: the JCI/CBA model shows greater detail of the standards, and measurement elements that guide the evaluation by the institution.
• Consideration of different professionals: the JCI/CBA model segments the standards in order to consider the different groups of professionals involved, unlike the ONA model that does not distinguish functions or professionals.
• Valuing people: the ONA model includes this element that is part of the factor "reward people." It was not identified in the JCI/CBA model.
• External customer rating: the ONA model guides the institution with regard to monitoring the satisfaction of external customers. The JCI/CBA model does not consider this item.
This research is classified as a case study, exploratory and applied, developed with a focus on people management standards in the hospital based on the comparative treatment of the main features of accreditation methodologies of the ONA and of JCI / CBA.
During the research, it was possible to determine characteristics of a specific reality and question the perception of hospital managers, expanding knowledge about the application of quality standards in hospital management.
Several sources, primary and secondary, were used in the literature review. The documentary research was based on data from documents, reports and internal information of the analyzed hospital. This raised theoretical material was the basis for the elaboration of a previous model of quality self-assessment.
The validation of the previous model was verified by the perception of participating hospital managers of research by applying a semi-structured questionnaire which had questions drawn from the quality standards related to people management.
The survey responses were standardized according to the Likert scale with the following ooptions: "I totally agree"; "I agree in part"; "Somewhat disagree"; "Disagree" and "I can not evaluate".
The questionnaire was structured in two stages - assessment of performance and relevance. The expectation of the first part was to identify what is the current situation of the analyzed hospital, considering the current practices relating to the people management. In the second stage, expected that the managers to point, according to their perception, the relevance of the proposed standards for self-assessment model, in order to contribute to the achievement/improvement of hospital quality. After the two stages, it was made available to managers an optional field of observations to point their thoughts and suggestions.
The questionnaires took place during the months of September and October 2015, in various sectors of the three areas present in the institution: administrative, medical and nursing, being preceded by approval from administrative direction.
Participated in the survey 28 managers, which represents about 80% of all managers of the research participating hospital.
Among the participants managers of the survey, approximately 70% are in their respective chief positions, coordination or direction for more than five years and work in the health area for at least 15 years. All have bachelor level in their fields and 30% have specific training in hospital management. Moreover, the four top managers of the institution, occupants of management positions (CEO, managing director, medical director and nursing director) completed the questionnaire.
The study was performed in a hospitalinaugurated in the 1950s, which is considered a health unit of high complexity of care, serving a region that cover a population estimated at over two million.
The data obtained from the questionnaire were very satisfactory and ratified the relevance of the questions. In all the patterns, managers showed total or partial compliance greater than 80% with respect to the relevance of the questionnaire items. This percentage confirms the perception of professionals about the importance of continuous assessment of quality standards. For this reasonthere was no removal of any question in the self-assessment final model.
The questionnaire applied was in person and there were no questions of interpretation at the time of filling the questions. The only adjustment in the standards was the dismemberment of the item that is regarding the analysis of satisfaction of internal and external customers, as suggested by one of the participating managers of research.
The items of the end of self-assessment model were also grouped based on subsystems of people management area (Add, Apply, Reward, Develop, Maintain and Monitor), in order to facilitate understanding of the issues that are presented with a structure more direct and orderly.
In this model, the questions should be evaluated under the performance point of view, in order to have the perception of the current state of the institution that makes the survey of quality. To this end, the suggested model continued with the same rating scale, with five response options in the initial model.
Thus, the final model of quality management self-assessment, with a focus on people management standards, in the hospital environment is provided in Figure 3, after the validation of the managers of the surveyed university hospital.
Figure 3. Self-evaluation model of quality management, with a focus on people management standards in hospital.
Source: Own elaboration
The comparison between the perceptions of hospital managers analyzed on the performance and relevance was drafted by the weighted average number of replies options for each items of the previous model of self-assessment. Because the answers are classified as categorized data, weights were assigned (numerical values) for each answer option. The "Not know evaluate" received the value 0, the "Totally disagree" received the value 1, " Disagree partially " received the value 2, "Agree partially" received 3 and the "Totally agree" received the value 4.
The use of this statistical tool made it possible to present a mapping of the perceptions of managers regarding the quality standards related to the people management in the hospital analyzed in the case study. The weighted average of the performance and relevance are presented in Table 1.
Table 1. Weighted average of the performance and relevance of the university hospital standards.
Source: own elaboration
According to the data collected, the weighted average on the performance was far below the weighted average relevance on most items. Item 2 was the one with the smallest difference between the performance and relevance, followed by items 4 and 6, which also had the smallest differences. Item 1 showed the greatest difference, followed by items 7 and 13, respectively.
It was noticed that most of the items with the highest weighted average relative performance and less difference between the performance and relevance were related to the subsystem of people management area "apply people", showing a strong point of the analyzed institution, which, according to the perceptions of their managers, it gives good results, especially with regard to the definition and description of positions.
Several items had a low performance and a high difference between the performance and relevance, according to the perceptions of managers. These items showed the weaknesses of the hospital and are connected, mostly to people management subsystems "reward people," "bring people together", "developing people" and "keep people." These questions expose difficulties of integration between the various professionals working in the hospital, few training initiatives and enhancement, as well as several other issues that adversely affect the working conditions of employees of this hospital.
Given these negative aspects found in the search, the hospital analyzed could develop and implement action plans in order to minimize or even eliminate the difference between the current unfavorable state and the desired situation. Below are some identified possible improvement actions/practices such as:
• Application of development programs aimed at the constant improvement of the staff;
• Development of actions that aim to value professionals with better performance and best results;
• Investment in infrastructure, including spaces and appropriate work equipment; • Stimulation of multidisciplinary activities involving teamwork with professionals from different areas.
However, we must ratify and disseminate the understanding of all standards addressed in the questionnaire, as well as demonstrate the perceived relevance of managers who constitute the management team of the institution, so that actions are actually designed, implemented and constantly monitored.
The survey indicated that there are many improvements that can be effected in the hospital researched in order to be potentiated the services provided, satisfaction and recognition of employees, and processes currently established under the people management.
In addition, the results indicated that managers understand the importance of standards that support the management and monitoring with a view to the continuous development of the institution. The comments added to the answers showed how the continuous monitoring practices can influence behavior that will be reflected in organizational improvements.
Thus, based on data obtained from the study, it was possible to develop a self-assessment model of quality management in the hospital, with a focus on people management, based on the present standards in the accreditation methodologies ONA and JCI / CBA. For the application of this model in other institutions, it is suggested to be carried out new research deepening the specific needs of the institution to be evaluated, so that monitoring indicators are set to be measured periodically in order to monitor progress and possibilities continuously improvements.
In the case of new applications of this model, from the data that are being collected, action plans could be created containing the challenges to be implemented, the form of execution, the deadline for completion and analysis of the impact achieved.
For managers of the research participant hospital was built a rating scale, maintained in the final model of self-assessment. However, the scale may be modified by future researchers so that it is more adherent to the one to be identified, not restricting the search to a single measurement format.
It is worth highlighting the importance of quality assessment for an organization, because regardless of whether or not in hospitals and of the analysis focus (people management, process management, infrastructure, etc.), it is understood that if there was a practice of constant monitoring in various areas, the quality of services provided, the commitment of those involved, whether managers or not, and customer satisfaction could be upgraded gradually, generating great benefits for the institution.
Finally, it is known that for a positive result, its necessary a great effort of all who compose the organization, since the creation of action plans and setting goals are fundamental. In this regard, it is believed that the application of a self-assessment model, as proposed in this work may be the first step to evaluate the current performance and identify points that need to be improved so as to achieve the expected results.
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