Healthcare Accreditation

Healthcare CBA’s newsletter ABout QuAlity And eConomiC developmentissn: 2318-0412 / volume 4 / numBer 1/2014

PeoPle are living longer and we must Pay more attention to continuous care, says david Bates, President of isQua

AccreditAtionAccreditAtion

risk managementLearn about the methodologies adopted to foresee risks

Quality and safetyUnderstand how administrative management can help

Palliative careWhen the patient’s well-being ‘speaks louder’

taBle of contents

4 IntervIewISQua’s President, physician and Professor David Bates analyzes healthcare in the world, especially in Brazil

7 ArtIcleInternational Relations Chairperson of CBA, the physician and researcher José Carvalho de Noronha talks about qualification in health through the ages

8 HospItAl IsrAelItA Albert eInsteInOrganization implements the Diabetes Program and reduces patients’ length of hospitalization

10 HospItAl MoInHos de ventoBriefing-debriefing methodology identifies risks to patient safety

12 HospItAl sAMArItAnoTechnology ensures quality and patient safety

14 totAl cAreProgram improves patients’ postural correction and decreases the number of surgeries

16 HospItAl do corAçãoOrganization trains Health Surveillance inspectors to audit patient safety protocols in Brazilian hospitals

18 pronepCorrect use of medical records reduces risk of infection and enhances effective communication

20 HospItAl sírIo-lIbAnêsSeeking life support, employees from all areas of the hospital are trained for situations of cardiopulmonary arrest

22 HospItAl AleMão oswAldo cruzOrganization invests in transparent and participatory management to achieve good results

24 HospItAl pAulIstAnoAdoption of PROMs tool to measure patient’s well-being brings customers and care team closer and improves corporate image

26 HospItAl totAlcorCare and administrative indicators measure results and underlie decision making

28 centro de pesquIsAs Aggeu MAgAlHães/FIocruzAccreditation provides improvement in quality and safety standards of the health care service, which was already a world reference in the study of tropical diseases

30 HospItAl MeMorIAl são JoséAdoption of new process improves management of inpatient beds

32 HospItAl 9 de JulHoMapping and risk management identify and seek to reduce situations that may threaten the safety of patients and professionals

34 AMIl resgAte New medical record form ensures more reliable information on patients’ transportation

36 HospItAl sAntA pAulASystem adopted qualifies physicians to work in the organization

38 HospItAl sAntA JoAnAPhysical and care processes restructuring improves care in the multi-emergency department

40 HospItAl AlvorAdAMethod adopted decreases the number of long stay patients

42 HospItAl dAs clínIcAs de porto AlegrePalliative care consolidates differentiated care to terminally ill patients

44 HospItAl são JoséImplementation of FMEA on the Oncology Service allows anticipated analysis of risks on the chemotherapy process

46 HospItAl donA HelenAAccreditation strengthens the culture of quality and safety adopted by the first hospital in Santa Catarina to obtain JCI’s gold seal

editorialmastHead

AssociAção BrAsileirA de AcreditAção de sistemAs e serviços de sAúdeRua São Bento, 13 Rio de Janeiro/RJ Telephone number: 55 (21) 3299-8200 www.cbacred.org.br [email protected]

BoArd of directors

Hésio Cordeiro Amilcar Figueira FerrariOmar da Rosa Santos

superintendency

Maria Manuela P. C. A. dos Santos

editoriAl BoArd

Maria Manuela P. C. A. dos Santos(Superintendent)

José de Lima Valverde Filho(Accreditation Coordinator)

Heleno Costa Júnior (Consultation Coordinator)

Rosângela Boigues (Education Coordinator)

depArtment of mArketing And communicAtion

Cristiane Henriques

technicAl review

Ana Paula Losito Heleno Costa JúniorJosé de Lima Valverde FilhoMoema Feitosa Nancy Yamauchi Regina MüllerRima Farah

editoriAl project And writing

SB ComunicaçãoTel.: 55 (21) 3798-4357

trAnslAtion

Laís Junqueira

grAmmAr proofreAding

Gerdal J. Paula

journAlist in chArge

Simone Beja

edition

Maria Cristina Miguez

texts

André BernardoDanielli MarinhoKarine RodriguesMaria Cristina Miguez

grAphic design

Maurício Santos

errAtA

In the last edition, the article about Pronep combines educational actions to technology and ensures business sustainability in which it read “on the last six months, with Move Care, index of medical record legibility increased from 88.9% of non-compliance in April to 100% in June, remaining in this per-centage over the past four months”. The correct is: “... index of medical record legibility increased from 88.9% in April to 100% compliance in June, remaining in this percentage over the past four months”.

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Accreditation history dates back to 1918, when, in the United States, the Ameri-can College of Surgeons surveyed 692 organizations based on minimum hos-pital quality standards and only 89 organizations met the pre-established

requirements. The alarming situation subse-quently boosted the creation of the Hospital Stan-dardization Program and the first manual of quality standards in that country. Over time and discussions between sector experts, the minimum standards gave rise to optimal achievable stan-dards and international standards of excellence.

In Brazil, Accreditation arrived in the 90’s as an innovative pro-posal and was seen by many as futuristic, considering Brazilian reality. But in 2005, the precepts of quality began to be more widespread and discussed and integrated into the policies of the Ministry of Health. CBA played an important part on this promotion through seminars, congresses and participation in several technical and scientific events throughout the country, both in public and private organizations.

This edition of Healthcare Accreditation magazine is a proof that “the future has arrived.” As we read the accounts of Brazilian hospitals accredited by JCI / CBA, we see the progress we achieved in quality and safety. There are several examples of excellence in health care. We can mention, among them, the health promotion programs con-ducted by Hospital Israelita Albert Einstein or by Total Care; methodolo-gies used to identify risks to patient safety, as described in the articles of the following hospitals: Moinhos de Vento, 9 de Julho, São José and also Amil Resgate; or the actions of palliative care implemented by hospitals Paulistano, Alvorada and Clínicas de Porto Alegre.

There are also articles that demonstrate that management, quality and safety walk hand-in-hand on a same direction as are the cases of hospitals Samaritano, do Coração, Sírio-Libanês, Alemão Oswaldo Cruz, Dona Helena, Pronep – Medicina Domiciliar and the Research Center Aggeu Magalhães unit of Fundação Oswaldo Cruz (Fiocruz).

If back then the standards of excellence in care were questioned, today there is no questioning about them. What about the future? Now we should ask: what else can we improve? Ahead, the certainty that is necessary to persist to improve more and demonstrate that what is most important is patient-centered care.

Enjoy your reading!

Maria Manuela Alves dos SantosSuperintendent of CBA

4 HeAltHcAre AccredItAtIon

IntervIew | by MArIA crIstInA MIguez

david batesChief of General Internal Medicine in Brigham and Women’s Hospital, Boston/USA; professor of medicine at Harvard Medical School; and president of International Society for Quality in Healthcare (ISQua)

He is chief of the Ge-neral Medicine Di-vision at Brigham and Women’s Hos-pital in Boston, USA, Professor of Medi-

cine, Harvard Medical School and has served as president of one of the most respected global organizations, whose mission is “to inspire, promote and support continuous improvement of sa-fety and quality of health care in the world”: the International Society for Quality in Healthcare (ISQua). In an exclusive inter-view, Professor David Bates, as he likes to be called, reveals the Accreditation in Health magazine sees as the health of the world and especially in Brazil. Bates also talks about the role of ISQua and points out ways to ensure quality and safety in health.

For its 31st Conference, the first one held in Brazil, iSQua chose to focus on Quality and Safety along the Health and Social Care Continuum. Why is this subject important?

The changes in demographics and the patterns of disease have drastically changed throughout the world in the last decade. More and more people suffer from non-communicable diseases, life expectancy is continually in-creasing and patients require con-tinuous care for longer periods. These conditions must be cared for at all stages of the care con-tinuum, from the community to highly specialised centres. Dif-ferent settings of care are need-ed and the interactions within them increasingly demand spe-cial approaches to deal with dif-ferent quality and safety issues.

Which are the major prob-lems in Latin America re-garding the promotion of qua l i ty and sa fety on health care?

Latin American countries are mostly at a transitional level of development. The resources and care in many large hospi-tals and big cities are as good as anywhere in the world, but in rural areas and small hospi-tals it is often quite limited. However, many countries in Latin America are very inter-ested in accreditation as a mech-anism for improving quality and safety in hospitals.

Which are the challenges on the implementation of care quality programs in middle income countries?

brazil can become the world’s leader in quality and safety in health care, says the president of Isqua

www.cbAcred.org.br 5

There are three major chal-lenges: assuring an appropriate dissemination of quality and safety culture through what is sometimes a very fragmented system of health care, providing care in areas where profes-sionally qualified staff are scarce and overcoming challenges to the quality of services due to financial constraints imposed by public and private funders.

According to the World Health Organization (WHO), bacterial infections are responsible for 25% of the deaths around the world and, if we consider just the less developed countries, they cause 6 of each 10 deaths. What can institu-tions and health workers do to minimize this problem?

Healthcare associated infec-tion (HCAI) is the most common harmful event in health-care delivery worldwide in both de-veloped and developing coun-tries. Hands are the main path-ways of germ transmission during any episode of care. Therefore, good hand hygiene practice is one of the simplest and most important measures to reduce the spread of health-care associated infections (HCAIs). Healthcare workers can protect patients and prevent the spread of HCAIs by perform-ing good hand hygiene practice at all times. Healthcare institu-tions can protect patients and prevent the spread of HCAIs, by

training and educating their staff on the importance of hand hy-giene and on the correct pro-cedures for hand washing, by conducting audits of hand hy-giene compliance and, by acting on the findings of those audits to continuously improve compli-ance with good hand hygiene practice. Recent evidence pub-lished by the WHO also high-lights the importance of hand hygiene practice in reducing infections caused by multidrug resistant bacteria in health fa-cilities. In one study, an increase in hand hygiene compliance from <60% to 90%, was associ-ated with a 24% reduction in Methicillin resistant Staphyloc-cous aureus (MRSA) acquisition.

The WHO has developed a suite of tools to support health care facilities in implementing mul-timodal strategies to improve hand hygiene practices among healthcare workers.

Other approaches beyond hand hygiene such as use of checklist in specific areas can also be very helpful.

The current health model, both at public and private institutions, has been seek-ing to improve its quality standard – locally and in-ternationally. However, there´s still a huge diver-sity of the professionals’ education in our country. What can be done to en-courage continuous profes-sional training?

There is definitely growing awareness throughout the world about quality of care and patient safety. ISQua for the past 30 years, has been a leading pro-moter of such awareness. When we go back to the 1980s towards the fundamentals of quality launched by Avedis Donabedian or the early 2000’s with the US Institute of Medicine report “To Err is Human”, when we see accreditation of health services disseminated among more than 80 countries in the world, we can see that progress has been achieved. Nowadays with all the resources that information tech-nology has provided in the healthcare field it has become much easier to reach young

“recent evidence

published by

the wHo also

highlights the

importance of

hand hygiene

practice in

reducing

infections caused

by multidrug

resistant bacteria

in health

facilities.”


health professionals. Electronic Medical Records are now part of the day to day care, even in low developed areas of the world. Telemedicine is enabling health professionals in remote areas to remain up to date in their fields and provide better care to their patients.

Patient safety concerns are global and as we move towards a blameless culture we begin to understand that we can learn from what went wrong in our practice. Initiatives like the WHO Patient Safety Alliance designing simple and practical solutions to improve safety have demon-strated success in disseminating a safety culture. Various coun-tries have developed strategies to promote it. As I understand the Oswaldo Cruz Foundation developed a website, PROQUA-LIS, which is developing a promising patient safety tool. Also I learned that the Brazilian Ministry of Health launched a National Programme for Pa-tient Safety last year which establishes a set of initiatives for patient safety.

There is an onus on all health care professionals to maintain their competencies through on-going professional education and training. In the majority of countries this is essential to maintain your license and privi-leges to practice.

What is iSQua’s positioning in relation to evidence-based medicine?

ISQua strongly supports the use of evidence-based medicine.

How can Accreditation con-tribute to the improvement of quality and safety in health care?

Any form of external evalu-ation, such as accreditation, encourages healthcare facilities and professions to examine and measure themselves, against a set of standards and identify areas to improve. Accreditation has the added bonus of provid-ing expert advice from a team of peers and the motivation to continually improve over a 3 or 4 year period. Accreditation when used at an organisation level provides a framework for patient safety that can help re-duce the burden of audits.

What message do you leave to the health profes-sionals around the world and, specially, those who work in Brazil?

Quality and safety is of grow-ing importance worldwide. Brazil is a country which is de-veloping rapidly, and is becom-ing a world leader. As it assumes that role, it is essential for it to develop effective strategies to improve the quality and safety of the healthcare delivered to its population. It should be pos-sible to Brazil to learn from the experiences of other countries, but will also be essential for it to develop its local solutions. ISQua would be delighted to help Brazil with this process.

“Patient safety

concerns are

global and as we

move towards a

blameless

culture we begin

to understand

that we can

learn from what

went wrong in

our practice.”


ArtIcle

José carvalho de noronha, Md, phdInternational Relations Chairperson of CBA

quality in health services: Who benefits from it?

Joint Commission Interna-tional, the most important and respected organism for surveying quality in Health Services and that has gran-ted accreditation to more

than 650 health care organizations in the world, has only two partners for joint accreditation: Fundación para la Acreditación y el Desarrollo Asistencial (FADA) in Spain; and Consórcio Brasileiro de Acreditação (CBA) in Brasil. This fact shows the commitment of these organiza-tions with patient safety and qua-lity in health care.

More than being an exclusive local representative for accredita-tion, CBA and its members have always had as their mission the quest for continuous improvement of quality and safety of care to the beneficiaries of health systems and services, either through inter-national accreditation and certifica-tion processes, whether through education and training.

This commitment started on the 90’s when little was talked about quality in healthcare. In 1993, through the Eisenhower Fellowship program, I went to Chicago, where I was introduced to the work of the Joint Commission on Accredi-tation of Healthcare Organiza-tions, which grants accreditation

to north – American organizations. During that visit, the interest of starting a process of accreditation in Brazil was born.

At the Conference of the Inter-national Society for Quality in Healthcare – ISQua in 1994, we at-tended a meeting on accreditation in Treviso and established contact with the representative of the Joint Commission and began the discus-sion on performing joint work in Brazil. Previous to the creation of Joint Commission International, we were invited to be part of a task-force with representatives of five continents to develop the first ac-creditation manual internationally applicable. We integrated, soon after, the board of Joint Commis-sion Resources, a subsidiary of The Joint Commission, in the early years of development of its ac-tivities in the international arena.

Over twenty years have elapsed, and due this history, CBA today plays an effective role in the two most important organizations promoting Quality in global health. Currently, there are members of CBA in the Accreditation Commit-tee and the JCI Standards Subcom-mittee. Recently, when ISQua cre-ated the accreditation program for accrediting bodies, we also par-ticipated in this initiative and today

we integrate the Accreditation Council of the society, cooperating to define the general policies of accreditation in the world. The 31st Annual Conference of ISQua hosted in Brazil, having CBA as one of the local organizers, shows that Brazil has acquired enough ma-turity to host and mobilize the world into discussing issues and solutions in Health.

Since CBA works with these organizations, it is able to display quality for its clients-partners through benchmarking or with the support of its members so that accredited organizations or orga-nizations seeking accreditation can develop and improve their internal processes, ensuring greater qual-ity in care and patient safety.

In processes of health qualifica-tion, there is no loser. There are exchanges of experiences and mo-bilization around a common goal: the improvement of Health. There-fore, it benefits organizations that promote quality in health care, accrediting bodies, professionals and, mainly, patients. It is a ‘game’ where there are no losers. Fifty four Brazilian organizations today are part of the privileged universe of the best 659 organizations ac-credited and certified by JCI Con-gratulations to the winners!


rate of HyPoglycemia (Below 6o mg/dl)

Hospital Israelita Albert Einstein (SP) was able to reduce the number of cases of hypoglycemia in inpatients through ac-tions coordinated by a multidisciplinary team of diabetes educators. Of the total of 219,000 glucose tests performed in

2008, 6,400 were below 60 mg/dl, ie, presented a glucose level considered below normal. Of the total of 318,000 glucose tests performed in 2013, only 1,719 presented levels below 60mg/dl. The 2.9% index of 2008 decreased to 0.54% in 2013. After the visit of surveyors from Consórcio Brasileiro de Acre-ditação (CBA) on the 16th and 17th of December of last year, the organization’s Clinical Care Program on Diabetes was certified by the Joint Commission International (JCI), represented in Brazil by CBA. “Our commitment to pursue certification was based on improving the quality and safety of care for inpa-tients with diabetes or without diabetes, at risk for hypoglycemia or hyperglycemia,” explains Roselaine Oliveira, consultant of the Board of Healthcare Prac-tice, Quality, Safety and Environment of Hospital Israelita Albert Einstein (HIAE).

According to the endocrinologist and coordinator of the organization’s Diabetes Program, Rogério Silicani Ribeiro, the guidelines of the program help to control the patients’ blood glucose, and also prevent adverse events and reduce the length of hospitalization. “These are the actions that I consider the most important to the success of the Diabetes Program: Identifying and training reference healthcare professionals to support the program activities; seeking the greatest possible consensus with the clinical staff and support of the governing body; and adapting the clinical recommen-dations to the hospital setting,” he says.

The program was created in 2006 based on the need to improve care of patients with changes in the rates of blood sugar. To render professionals with more training than most professionals already work-ing on direct patient care, the organization developed a basic training course for educators on diabetes. The nurse Magda Tiemi Yamamoto, who works in the program since its initial phase, explains that the policies, procedures and protocols regarding patients with diabetes, hyperglycemia and hypoglycemia are established according to the recommendations rec-ognized worldwide, adapted to the standards of the organization and revised periodically. The policies and protocols are updated annually, and all the documen-tation from the hospital is updated every three years. “The JCI/CBA standards certainly contribute for us to make improvements in our processes and conse-quently in our documentation. Our documents are managed consistently and uniformly, according to

glycemia under control

Hospital israelita albert einstein implements the diabetes Program and reduces the length of patient hospitalization


the organization’s internal policy, which was based on JCI’s recommendations,” says Oliveira.

Once the documents are compiled and structured, the set of policies, procedures and protocols related to patients with diabetes, hyperglycemia and hypo-glycemia is forwarded to the Endocrinology depart-ment – composed of physicians of the hospital’s clinical staff – for review. “Endocrinologists evaluate the proposed actions and validate those considered viable. Thereafter, these become protocols and be-come part of the hospital’s routine,” adds the nurse Thalita Barrier Modena, who is also a member of the program. The next step is to submit it to all the other departments of the organization such as cardiology, orthopedics and neurology.

According to the program coordinator, JCI certifi-cation brought several benefits to the quality and safety of care provided, including the adoption of the rate of hypoglycemia as one of the goals of organi-zational safety; the reformulation of the training plan related to the topic; and the creation of strategies to improve the results of adherence to the Diabetes Program. “The certification increased the mobilization of professionals working in an environment focused on continuous improvement and quality standards,” ensures Ribeiro.

controlling the diseaseAccording to the consultant of Quality of HIAE, the target population of the Diabetes Program are inpa-tients older than or equal to 18 years old, with dia-betes, on hypoglycemic agents; or non-diabetic pa-tients with hyperglycemia or hypoglycemia. In the admission process, the care staff tracks the capillary

glycemia (CG), identifies the presence of diabetes, use of hypoglycemic medications and the risk of hy-poglycemia or hyperglycemia. At that moment, the patient is appointed to be included in the protocol and the educational process for patients and their families starts. “In addition to these activities, the program performs an active search of the capillary glucose of all eligible patients; and by the average of capillary glucose, promotes active and early inter-vention on patients with hyperglycemia or hypogly-cemia tendencies,” explains Roselaine Oliveira.

This attention is justified by the fact that hospi-talar hyperglicemia increases the risk of infection and death, especially in complex surgeries which can reach up to 35% of inpatients. In intensive care units, the risk can reach 50%. The presence of hyperglycemia negatively affects the clinical evolution of inpatients. According to medical literature, each increase of 50 mg/dL increases the perioperative mortality in non-cardiac and non-vascular surgeries in 52%; quadruples the risk of complications such as renal failure, sepsis and death in patients with parenteral nutrition; and adds an amount of U$1,769 to the cost for patients undergoing revascularization.

Although diabetes has a high prevalence and negatively influences the patients’ life in the hospital, the diagnosis is usually omitted in the admission, progress notes and discharge documentation. In most cases, diabetes is a secondary diagnosis and the phy-sician is focused on primary disease such as a heart attack or pneumonia,” stresses the program coordina-tor, adding that the blood glucose screening during hospitalization allows an active search for cases with glycemic changes, increasing the detection of patients with hyperglycemia and hypoglycemia.

Av. Albert einstein, 627 – MorumbiSão Paulo/SPTelephone number: 55 (11) 2151-1233www.einstein.br


Tool which allows the identification and anticipation of potential problems that could jeopardize patient safety. That is the briefing-debriefing technique which aims to increase the culture of patient safety. It has been used by Hospital Moi-

nhos de Vento (RS) for one year.With the implementation of the tool, the idea is

to meet the International Safety Goals established by the Joint Commission International in partnership with the World Health Organization and the Ministry of Health, such as: identify patients correctly, reduce the risk of patient falls, reduce the risk of health care-associated infections, ensure correct-site, correct-procedure, correct-patient surgery, ensure the safety of high-alert medications and improve effective com-munication. According to Vânia Röhsig, healthcare superintendent of the organization, some results have emerged, such as identification of infection risks in patients with resistant germs and the replacement of the identification bracelets for better visualization of patient data. “Safety briefings are a simple and user-friendly tool. The front-line staff can use it to share information about potential safety problems and also their daily safety concerns without fear of reprisal” says Röhsig. According to her, the technique that can be carried out in different ways, has been adapted to match the hospital’s needs.

The goal is to present subjects related to quality and safety, always focused on the six interna-tional safety goals. “This subject is aligned to inpa-tients and outpatients.

Support areas that have direct influence on patient care, such as Pharmacy, Accommodation Services,

Physical Therapy and Infection Control, are also part of this process” says her.

A structured form that seeks to identify risks in various areas of the hospital is used. The risks can range from a problem of lack of signage on the hall-ways to patient fall risk.

planning the dayThe briefing is held at the beginning of the shift, when teams stop for five minutes to talk about the proposed subject. At this meeting, the following questions are answered: What risks we have in this area today?; What measures will be taken to ensure that the risks do not become facts?; What will we do if any non-compliance occurs? The answers are shared with the team, which makes patient care safer, considering that the team will now be more atten-tive to the risk.

On the debriefing, held at the end of the shift, the same team meets for other five minutes to answer the following questions: Did we have any adverse event today?; What actions were taken?; What are the proposed changes or actions taken?

At this stage, the team analyzes what occurred and which measures could be adopted to help avoid future risks.

An example of the potential risks identified during the use of this tool by the organization was related to patient falls in the waiting rooms. According to Röhsig, during one of the weekly meetings, it was pointed out that this type of risk was caused by chairs with casters, that moved around when the patients stood up. After the identification of the problem, this

anticiPating ProBlems and risks

Hospital moinhos de vento invests in a tool that identifies risks to patient safety


type of chair was replaced for another chair. Another possible risk reported was the erasing of data on the inpatient identifica-tion bracelets. “We found that there was a variation on the ink used on the identification label and the data on the patient bracelet would be erased during long-term hospitalizations. When we found out about this problem, we replaced the type of iden-tification bracelet used” she explains. Every week, the results of the briefing-debriefing are compiled and presented at a meeting with the leaderships. Thenceforth, action plans are created in order to

implement improvements. According to Röhsig, in a period of six months, there are more than 60 actions listed and more than 80% are already implemented.

Today, for example, the care staff reviews which patients are at fall risk in the sector at every shift change. “If he is an anticoagulated patient, from on-cology, with calcium deficiency, there is a greater risk of fracture. This control is done so that the staff knows the patients, prioritizes care and knows which actions must be taken if the risk is present”, says the care superintendent.

For Vânia Röhsig, the Joint Commission Accredi-tation Standards for hospitals supports the organiza-

tion on the compliance with the International patient safe-ty standards, especially in the section discussing organization and management of health care. She points out that the chapters that discuss the Im-provement on Patient Safety Quality and Prevention and Control of Infections are in agreement with the tool ad-opted by Moinhos de Vento.

“We know we have to meet the six international

safety goals. The challenge is to keep staff aligned and following the routine to ensure quality and safe-ty for patients and professionals” stresses the health-care superintendent of the hospital.

R. Ramiro Barcelos, 910 – Moinhos de VentoPorto Alegre/RSTelephone number: 55 (51) 3314-3434www.hospitalmoinhos.org.br

“The briefing-debriefing is an

important technique that can

be performed in different ways.”

vânia rohsig, healthcare superintendent


Following the trend and the demand of the healthcare market, Hospital Samari-tano (SP) completes 120 years of activi-ties and adopts a new market positioning, which prioritizes specialized medicine. The organization that is reference on high

complexity procedures in healthcare, intends to invest around R$ 30 million in 2014 and imple-mented greater competence specialties depart-ments: Orthopedics, Cardiology, Neurology, Gas-troenterology, Oncology, Urology and Gynecology, Obstetrics and Perinatology.

The goal of these centers is to provide complete integrated care to patients, following up all steps of treatment. According to the medical superintendent of Samaritano, Dario Fortes Ferreira, “the change of po-sitioning is due to the fact that the hospital has been accredited by Joint Commission International (JCI) for ten years, which motivates con-tinuous reviews, innovation and constant developments in the area of health,” he says.

Within the concept of high complexity in spe-cialized areas of medicine in which the hospital is a referral center, pioneering and innovative surger-ies were performed in 2013: endoscopic surgery for correction of spina bifida (myelomeningocele), renal transplant in which patient and donor had different blood types and the implantation of ar-tificial heart. Myelomeningocele is a congenital

disorder characterized by a malformation of the pro-tective structures of the cord, which affects the baby in the seventh week of intrauterine life. To make the correction, an innovative and 100% Brazilian tech-nique was used.

According to the superintendent, the successful implantation of the artificial organ was only pos-sible because the several hospital processes were perfectly adjusted, such as hospital infection con-trol, certification of central sterilization, a surgical center fully equipped for this type of surgery, well

described and appropriate anes-thetic procedures, following the WHO protocols for safe surgery and compliance with other pro-tocols. In addition to that, to achieve the best results, the organization follows the safety standards recommended by JCI such as patient safety goals, safety on all steps of the system medication management and use and reduction of risk of hos-pital infection. “The most im-

pressive results are in neonatal medicine in which we work with a treatment success rate and mortal-ity well below the world average. The results are also highly positive in the cardiac intensive care unit. As a result of the adoption of the protocols, we had, in 2013, for example, no deaths from acute myocardial infarction in the hospital. This means that our mortality was zero” says the med-ical superintendent. Besides excellence in high

sPecialized medicine

Hospital samaritano invests in technology to ensure quality and patient safety

“the most impressive

results are in neonatal

medicine” dario fortes ferreira,

medical superintendent


complexity surgical procedures, Samaritano main-tains a treatment center for stroke, which extends from the time of admission to post-discharge re-habilitation, and a trauma center. According to Ferreira, the organization has maintained high conformity in compliance with protocols in these specialized centers.

clinical governanceAnother highlight is the project of clinical governance – the implementation of the management model based on the precepts recommended by National Health, UK. The goal is to maintain full compliance with those requirements. Accredited by Joint Commis-sion International (JCI) in 2004 and re-accredited by the third time in December of last year, the organiza-tion also has among its objectives, the goal to increase the degree of multidisciplinarity in patient care.

With these actions, Hospital Samaritano aims to achieve zero harm to the patient in 2020, as recom-mended by the Canadian Patient Safety Institute. “We have this long-term goal, associated with JCI, to achieve zero damage in 2020” says the medical superintendent. “Accreditation is a major driver for improving quality in care. It is an award, not a goal to be achieved; the goal is to ensure quality and patient safety. Using the methodology of Joint Com-mission International is helping us get closer to that goal faster on a more consistent and more lasting way,” says Dario Ferreira.

R. Conselheiro Brotero, 1.486 – HigienópolisSão Paulo/SPTelephone number: 55 (11) 3821-5300www.samaritano.org.br


Data from the World Health Organization show that approximately 80% of the world population suffers or will suffer some type of pain at some point of their lives. To contribute to the improvement of these patient’s quality of life, Total Care

(SP) implemented the Postural Correction Unit (UCP), coordinated by the physical therapist Patrícia La-combe. Since then, the organization has achieved advances in the physiotherapy service and hence reversed severe clinical conditions.

The UCP implemented in 2005, aims to address severe cases, preventing future sur-geries; and to initiate the pro-cess of education and preven-tion for patients who reported pain but did not suffer from any pathologies. “Often, the person has pain, but has no injury such as a herniated disc, for example.

Then, therapeutic and pre-ventive protocols are applied, prioritizing the education to change bad daily habits, which usually are the great villains for these spinal injuries,” clarifies Lacombe, coor-dinator of UCP-Total Care, which provides care to approximately 3,000 cases per month.

Relying on a multidisciplinary team, each case is individually assessed and ranked among less conser-vative treatment and more conservative treatment. “Most cases already need surgery because they are in advanced stages.

However, with another group of patients, we can work without surgeries,” says Lacombe, high-lighting that even when there is surgical indication, the work of UCP shows results, presenting a reduc-tion of 75% of cases regarding this indication. “And when the person does not have a real indication for surgery, but has an injury, this number increases to 94%,” she adds.

According to the coordinator of UCP, several tech-nical indicators and administrative protocols are used for this classification. Among technical indicators

there is a behavioral pain scale system and a questionnaire, which addresses five domains, including physical pain and psy-chological pain in order to assess the patient comprehensively. Combined with this process, the organization applies another questionnaire that measures the patient’s degree of disability at the time of assessment and the patient’s progress throughout the treatment. “In addition to these parameters, we use another type of objective evaluation called inclinometer, which is a device

that measures the degree of flexibility of the spine,” adds the professional.

MonitoringBesides the technical protocols, there are administra-tive protocols, such as control of daily exercises that should be done by the patient at home. Through

Quality of life

total care’s program improves patients’ postural correction and decreases the number of surgeries

“we realized that 48% of the patients

carry out the exercises one year

after they are discharged.” Patrícia lacombe,

coordinator of the Postural correction unit


telephone contact, the team responsible for UCP monitors whether the patient is following the treat-ment and post-treatment exercises; if there is recur-rence of pain; or search for appointment or an examination for the same pathology. “We realized that 48% of the patients still do the exercises for one year after they are discharged,” Lacombe states.

Exercise sessions occur in groups or individu-ally, according to the need of each patient who undergoes a series of assessments to identify de-ficiencies and limitations. Based on these results, the section in which the individual must participate

and the movements the patient will need to per-form are established.

The treatment is characterized by the promotion of autonomy, increasing body awareness and pa-tient’s knowledge about his own body so that, thereafter, the patient can understand what is bad and what not to do, or how to protect his body. At discharge, the patient must be aware of the well-being that the exercises provide to the body and shall be able to follow the exercise program by himself. The support of holistic fitness which consists of more than 800 movements and perceptions of the body prevents various diseases, such as changes in spinal lesions in the upper and lower limbs, fibromyalgia and scoliosis.

The method implemented for pain improvement is different. Instead of rating pain on a scale of 0 to 10, a questionnaire is combined with the numbering of this scale. That way, the patient can report the type of pain more specifically. “Sometimes, the patient that undergoes a surgery is not a patient that has a momentary sharp pain that improves with medication. Usually, that is the start of the pathology. But the patient who experiences chronic pain does not nec-essarily have a high pain score, instead, he feels an incapacitating pain on a daily basis,” says the coor-dinator of UCP. This means that, according to this scale, if the patient presents daily pain – the equiva-lent to stage 6 on the scale of zero to ten – new investigative questions are asked such as if the pain disrupts daily activities. It is disrupts sleep, for ex-ample, the patient is already in the range between 9 and 10. “This detailing allows the team to monitor the progress of the patient,” she says.

Lacombe explains that goals are established and results are analyzed. One of the goals is to decrease pain in at least 50% in the first reassessment; another goal is adherence, which, she says, is more difficult to achieve: “In this goal, the result is not satisfactory. Ie, about 30% of patients fail to complete the 27 weeks treatment. We do not reduce the pro-tocol because we understand that 27 weeks is the ideal period of time to safely work around the cause of the problem, and not the consequence of it. The traditional physical therapy usually works exclu-sively on the patient’s pain. Then, the patient returns in two or three months with the same problem, that will progress over time. The idea of the protocol is to look at the patient as a whole,” emphasizes the coordinator of UCP-Total Care.

Cincinato R. Cincinato Braga, 340 – 17º andar – Bela Vista

Jardins Av. Nove de Julho, 5.837 – Jardim Paulista

Telephone number: 55 (11) 5112-1000www.amil.com.br


education for Patient safety

Hcor trains national Health surveillance inspectors to audit patient safety protocols in Brazilian hospitals

The creation of Ordinance No. 529, April 1st, 2013, of the Ministry of Health (MS), esta-blishing the National Program for Patient Safety (PNSP), and the publication of the Collegiate Board Resolution, RDC No. 36, of July 25, 2013, by the National Health Sur-

veillance Agency (ANVISA) establishing that all health services must establish measures for patient safety, brought a new mission to Hospital do Coração (SP). HCor, as the hospital is known, was chosen to train professionals working in the National Health Surveillance System (SNVS) in good inspection prac-tices, emphasizing risk management, patient safety and quality of health services. The goal is to train SNVS professionals to verify if the hospitals inspected are meeting the requirements of RDC 36, as the ope-ration of Centers for Patient Safety and the adoption of patient safety protocols, which must be developed based on relevant scientific information. The Com-mittee for the Implementation of the National Program for Patient Safety (CIPNSP) has recently published patient safety protocols. These protocols consider the guidelines and orientation set by the World Health Organization (WHO), with the collaboration of the Joint Commission International (JCI).

Graziela Trevizan Da Ros – nurse researcher at the Laboratory for Innovation in Engineering, Manage-ment, Evaluation and Regulation of Policies, Systems, Networks and Health Services (LIGRESS) from the hospital’s philanthropy department – tells that HCor initiated a project for educational strategies in 2012. However, with the Ordinance and the RDC 36, came the demand to empower participants in the observa-tion of processes and work flows, considering the

scenario in which risks can be inserted and possible improvement of issues concerning relationships be-tween work teams. Since the hospital is accredited by JCI and already works with international patient safety goals, ANVISA invited the organization to pro-vide trainings for Health Surveillance auditors in Good Inspections Practices in Health Services with focus on Patient Safety” explains Da Ros.

She complements adding that “due to HCor’s expertise in best practices management, we orga-nized a training schedule based on a real experience. That is, showing what was successful and what was not during the deployment and maintenance of these protocols in a process to review, learn and correct failures. Patient safety is linked to the behavior of people and the implementation depends on the de-gree of adherence not only to the regulatory obliga-tions but to attitudes towards safety, using the prem-ises of ongoing education”.

the projectThe development of the project occurred from the proposition of developing a manual of good prac-tices for inspection and an inspection roadmap (both under validation process by ANVISA/SNVS), followed by the methodology of theoretical and practical training for professionals in health care. The manual is intended to provide basic information to the audi-tors of ANVISA regarding the inspection of patient safety standards in health care. In it, we present the definitions of actions for patient safety in health care services and the procedures to implement the six patient safety goals are detailed.


R. Desembargador eliseu Guilherme, 147 – ParaísoSão Paulo/SPTelephone number: 55 (11) 3053-6611www.hcor.com.br

The method begins with the problematization of real situations so that participants can discuss them. The next step is to propose interventionist measures to remedy the problem observed. According to the nurse, the goal of the manual is to assist the activi-ties of inspection and ensure that the inspection is developed in a standardized way that respects the global guidelines for patient safety and thus enables a system of partnership between the health surveil-lance agencies and the audited services.

To develop the training project, Da Ros explains that a team was created in HCor, consisting of Con-tinuous Education nurses, physicians, Quality and Safety department staff members, risk manager, pharmacists and hospital infection control department staff members. In addition to this multidisciplinary team, ANVISA and Health Surveillance staff were also part of the development of the training. “First, we developed the Manual of Good Inspection Practices in Patient Safety, focusing on the safety protocols of the Ministry of Health and an inspection roadmap. The training was carried out in five days: two days in the classroom and three days of hands-on activi-ties, in which 30 students visited five sectors of HCor: ICU, Operating Theater, Emergency Department, In-patient Unit and Pharmacy”, she explains.

Two members of the Health Ministry, together with ANVISA’s team, evaluated the teaching metho-dology used by HCor. Another important factor high-lighted by Da Ros was the feedback given by the participants: “In the discussions raised by the group, some areas for improvement in HCor were pointed out because the participants visited the units with auditing eyes. We knew that the failures could be

identified and we did not hide our reality. HCor values transparency and that demonstrates a high level of safety culture. They also made suggestions of im-provement for the service itself and for the inspection roadmap that was developed together with ANVISA. That helped us improved our activities”. The nurse researcher adds that “with the findings, we observed non-compliances that were solved by the leaders of each department together with the team of the hospital’s Quality and Safety Service. Thus, we could improve the quality of our processes, achieving greater safety for our staff and our patients. “

After training, a report was developed. It in-cluded the training’s evaluation, reviews and sug-gestions raised by participants. This document was shared with the Superintendent and the managers of each department visited in HCor, for the purpose of continuous pursuit of processes improvements.

Graziela Da Ros explains that the idea is to standardize one language to the health care orga-nizations in Brazil in order to assist them in imple-menting Centers for Patient Safety as it is now required by law.


Reducing the risk of infections associated with health care and improving the effec-tiveness of communication through correct use of the medical record. These are two of Pronep’s goals. The organization has home care units accredited by the Joint

Commission International (JCI) in Rio and São Paulo. Since the organization achieved JCI’s seal of quality in 2007, it has recorded a reduction of 49% in the incidence of infection, being 46% reduction in respi-ratory infections and 70% reduction in urinary tract infections. Furthermore , since the implementation of the international accreditation process, there was an improvement of 24% in medical records compliance. “When an organization seeks accredita-tion, it seeks, in fact, an orientation. Accreditation came to guide Pronep on a certain direction: what needs to be done so everything happens as planned. The accreditation manual provides the necessary information to achieve the quality and safety of care that we seek,” states Luciana Lima, general Manager of Pronep-SP.

With the goal of ensuring the safety of home care, Pronep implemented the Home Infection Control Committee (CCID) to identify and reduce the risks of transmission of infection to the patient, family mem-bers, professionals and visitors. Through a program of surveillance, prevention and control of infections, strategies for education and training techniques for hand hygiene were implemented for all the staff, acknowledging that this is a primary, preventive and essential measure for the control of infectious events.

certified Program

Pronep reduces risk of infections and improves communication effectiveness through correct use of the medical record

“The more people around the patient, the greater the risk of exposure to infection.

In this aspect, hand hygiene is a precious ac-tivity that should not be trivialized, considering that there are many professionals, including technicians and caregivers who interact with this patient daily,” says Alessandra Maranhão, operations general manager of Pronep-RJ.

Whereas the area of care is the patient’s home, the organization understands that, from a microbio-logical point of view, the home environment is not as risk-free as it seems. “Risks of cross-infection can be lower than in the hospital environment, but they

evolution of tHe indicators – ACCREDITATION PERIOD 2007-2014


exist and require prevention and control actions,” Lima highlights. Monitoring of materials’ inbound and outbound, the disposal of waste generated in the patient’s home and the technical visits to outsourced companies are examples of actions against these risks. “The educational work with the family is continuous, daily and unremitting. The hygiene process is strict and not restricted to the hands. Even the places where certain products will be stored must be properly sanitized. Most of the times, Pronep performs a real transformation in the patient’s home environment. Not all family members understand the need of it. Our only concern is to mitigate the risks of infection in the home environment,” Maranhão explains.

pursuit of excellenceAs one of the differentials of Pronep is the relentless pursuit of operational safety, the organization per-forms a strict monitoring of the home care provided through the medical record: a set of mandatory documents for exclusive use of healthcare profes-sionals involved in the patient’s home care, which includes all clinical and non-clinical information of an individual. To Pronep, the medical record is the main link between health care professionals, en-suring a proper standard in multidisciplinary com-munication and continuity of care. The organization recommends that the patient record is filled out with clear, concise, legible handwriting and without erasures. When this recommendation is followed, the risk of failure in communication between team members is minimized.

Two of the international patient safety goals fol-lowed by Pronep are directly related to the medical record. The first goal calls for the correct identification of patients through at least two indicators, such as the full name and date of birth. The nurse respon-sible for the patient should consult thoroughly and systematically these two identifiers upon receiving each file and / or document. Likewise, every profes-sional involved in the care of the patient should check the patient’s data before performing any procedure. The second goal aims to establish an effective, com-plete and unambiguous communication between the various home care professionals. In addition to the information in the medical record, Pronep ensures correct verbal communication, which is noted in the medical record after the read-back process by the person who receives the information.

“Because of the staff turnover, Pronep conducts constant audits to ensure that the medical record of the patient is being properly filled out. It is important that, upon arriving at home, the health professional – physical therapist, speech therapist or psychologist – is able to visualize all home care that is being provided, and therefore, continue the treatment pro-posed,” Lima states. Pronep-SP’s operations general manager adds that the medical records are analyzed monthly by a commission for further action and im-provement plan. “The medical record is the main tool we have to ensure continuity of care. It is the portrait of the care provided,” adds Alessandra Maranhão, operations general manager of Pronep-RJ.

Rua Bagé, 112 – Vila Mariana – São Paulo/SPTel.: 55 (11) 5904-4444

R. Visconde de Silva, 125 – Humaitá – Rio de Janeiro/RJTelephone number: 55 (21) 2538-5555

www.pronep.com.br


The person accompanying the patient goes to the toilet and, suddenly, faints after su-ffering a cardiopulmonary arrest. Besides the hospitality staff member, there is no one else around. Although he is not a phy-sician, the staff member is able to act

appropriately to the situation and therefore, imme-diately dials Code Blue, a phone number that acti-vates the rapid response team. Thus, in about two minutes, the emergency team arrives on site and initiates the resuscitation techniques. The scene is fictional, but would not cause further problems if it occurred in Hospital Sírio-Libanês (SP), that decided to train all the staff, even physicians from the open medical staff, and employees who do not have direct contact with patients.

“Because we are a hospital of excellence, our main concern is patient safety. So we decided to train all employees, regardless of their work position and area of expertise. We have several types of training; from the one focused on lay people so they can iden-tify a situation of cardiopulmonary arrest and trigger

the team in charge of care; to the more specialized professional who provides advanced life support,” explains Bruna Infantini, hospital Organizational Development Manager.

The training is part of the Life Support project and is provided in three levels, which differ according to the staff member job position: advanced level – face-to-face learning; advanced level – distance learning; and basic level – distance learning. The face-to-face learning is provided to physicians and nurses working in emergency or critical units, such as ICUs, and in places where there is a high potential for a cardio-pulmonary arrest such as the cardiology unit and emergency service. The training is held in two days and is certified by the American Heart Association. “It is the most complete and advanced certification there is. They receive materials in advance so they can study and perform theoretical and practical tests. The professional must have a minimum score to be certified”, explains Infantini.

In addition to the classroom training, since Febru-ary 2012, three other life support courses are being

full life suPPort

Hospital Sírio-Libanês trains all employees on cardiopulmonary arrest situations

status of life suPPort training (odl mode and traditional learning acls/Pals)


taught in Distance Learning (ODL) mode, through an online platform. The advanced training is divided into adult and pediatric and is aimed at those who provide care to patients in non-critical units. To com-plement it, on-site sessions are held for demonstra-tions on CPR and positioning and adequate movement of the patient. The basic course is focused on lay people who work, for example, in administrative areas. These individuals are trained to recognize a cardiopulmonary arrest victim and make the appro-priate call of the Code Blue.

Among the advantages of ODL, the organiza-tional development manager of Sírio-Libanês high-lights the possibility of training more staff members in less time, expanding the coverage of training and reducing logistics costs. “We have people working at all times, in different shifts, because the hospital is staffed 24 hours a day, 365 days a year. And ODL makes it easier to reach all employees,” she notes, adding that the announcement of the training is done through the hospital’s intranet and also by organiza-tional email. The online system monitors the logins, pointing out how many people have already com-pleted the training and how many failed to get the minimum score and therefore must retake the course.

comprehensive trainingAccording to Infantini, the program differential is that the training also reaches physicians from the open medical staff, an initiative that required an action plan for improvement that started on January this year. “We were on the path of training 100% of the staff but we still had to train the physicians from the open medical staff. So we did a task force and defined

R. Dona Adma Jafet, 91 – Bela VistaSão Paulo/SPTelephone number: 55 (11) 3394-0200www.hospitalsiriolibanes.org.br

a plan of action involving several areas of the hos-pital”, explains the manager, stating that the initiative is achieving great results.

Until the end of March, 97% of the 5,561 staff members of Sírio-Libanês had completed the training. Further analysis of the data shows that the majority of staff, consisting of 5,132 people, occupy roles that make them able to take the course in ODL mode, and 98% are already trained. In the case of the 429 em-ployees who need to take the traditional learning course, the proportion was slightly lower: 96%.

Providing the necessary training so that staff acts appropriately when facing a cardiopulmonary arrest is a standard required by the Joint Commission Inter-national (JCI) Accreditation Standards for Hospitals. According to Bruna Infantini, the standards were taken under consideration during the development of the Life Support Project: “International accreditation standards guides us, especially the chapter Staff Qualification and Education (SQE) that addresses the qualification, skills and education of the professional, how the organization trains the professional so he is able to provide care in compliance with JCI standards.”


adHerence to tHe VENOuS THROmbO-emBolism (vte) Protocol until 24H after admission

senior leadersHiP and Quality

Hospital alemão oswaldo cruz invests on transparent and participatory management to achieve good results

density of Bloodstream infection – icu

One of the main changes on the 5th edition of the JCI Accreditation Standards for Hospitals regards the revision and expan-sion of the Governance, Leadership, and Direction chapter. There was a significant increase in the number of standards and

requirements, making the main instances and pro-fessionals responsible for the management of the organization accountable of the real operation of services. In addition to that, they are directly respon-sible for the use and monitoring of performance in-dicators and the overall quality and safety of care management plan.

In Hospital Alemão Oswaldo Cruz (HAOC), in São Paulo, this level of requirements seems to be already consolidated due to the plan established by the or-ganization’s Senior Management and the involvement of leadership towards care, social and market out-comes. According to Marcelo Lacerda, the strategic map of the hospital is based on research and applied

methodology, together with the study of the healthcare market and internal data such as analysis of the epide-miological profile of patients. He ex-plains that regular meetings are held with senior leadership to present the goals, keep track of what was per-formed and formalize the next actions.

To motivate the senior leadership and their staff, the hospital adopted the Institutional Program of Quality and Safety which monitor processes and health care indicators. “We have over 100 strategic indicators and 74 of which relate to quality and safety,” said the President of HAOC. According to him, “the program includes meet-ings regarding strategic issues and the management of processes, so we can identify gaps and opportu-nities for improvement.”

JCI accreditation, according to the President, assists the hospital (accredited since 2009) in their processes management. “We see JCI as a complete methodology that approaches care processes and also support processes, as a whole, to promote safe patient care. The standards and the measurable elements provides us a more objective way to assess how we are performing and evolving”, states Lacerda.

Active participationAs a way to encourage teamwork, the leadership also encourages a collaborative and integrated environment. Patient care is based on the RBC model (Relat ionship-Based Care) and is the

Marcelo Lacerda


responsibility of all areas of the organization, from care areas to support areas.

“With some essential training, such as Interna-tional Patient Safety Goals and “HAOC’s Way of Being and Caring” the organization reinforces acceptance and respect on patient care and also in support areas. We are recognized as the best Nursing in Brazil and everyone watches over this reputation,” the President proudly states.

Transparency and respect for employees, accord-ing to him, are the strengths of HAOC and the reason for such a positive corporate image. “Our policies, bylaws, programs, routines and all the structure of organizational documents are available and can be accessed by all,” emphasizes Marcelo Lacerda. The president keeps open channels to both the senior leadership and other employees, such as meetings with the executive superintendent and other super-intendents. The hospital also adopts an annual per-formance review, “with which all employees have the chance to perform a self-evaluation and receive feedback from senior leadership. Thus, it is possible to encourage the professional development of staff, pointing out successes and opportunities for improve-ment,” adds the manager.

From the standpoint of accreditation, the hospital has adopted an internal methodology, in which each chapter of JCI manual has a leadership that chooses and invites employees from different areas and posi-tions to be part of the process. Monthly meetings are held with the group for monitoring of indicators, rou-tines and other specific characteristics. The program Terças-feiras de Qualidade e Segurança (Quality and Safety Tuesdays) promotes internal audit of care ar-eas, fortnightly, with focus on the International Patient

Safety Goals. “Anyone in the organization can volun-teer to be part of the auditor group, which now has more than 40 people,” he states.

The Risk Management System that deals with adverse events and near-misses contributes to the effective participation of employees, patients and families, with the goal of improving the quality and safety of the service. To this end, four ballot boxes are positioned in the hospital so the individuals can describe possible misses or errors. “There is no need for identification of the person who writes the noti-fication”. The senior leadership encourages maturity in matters of risk management, avoiding punishment and encouraging notifications to enable continuous improvement,” ensures Lacerda.

These mechanisms assist on the construction of a plan of service that meets the needs of the patient, the community and the market. According to the president, the study and analysis helped establishing the focus areas of HAOC (circulatory, digestive, on-cological and musculoskeletal diseases). “We have also developed the management of clinical protocols, which are essential to generate quality of care indi-cators. This ensures the best possible outcome for our patients, establishing a relationship of trust with them” emphasizes the manager.

Marcelo Lacerda concludes by saying that HAOC seeks the maintenance and development of quality of care with processes and efficient costs to ensure competitiveness. “For this reason, we have a solid annual planning, in accordance with goals and objec-tives, and with the participation of management and senior leadership. Today, we offer the best conditions for the practice of medicine with constant investment in technology and infrastructure adequacy.”

R. João Julião, 331 – ParaísoSão Paulo/SPTelephone number: 55 (11) 3549-0000www.hospitalalemao.org.br


Improving the quality of life of patients and fa-mily members in the palliative care service. With this mission, Hospital Paulistano (SP) has adopted patient-reported outcome measures (PROMs) one year ago. The tool consists in sys-tematically applying a specific validated ques-

tionnaire for patients in palliative care. The tool covers various aspects of the human suffering and aims to detect one or more symptoms, assess its intensity, quantify the response obtained with the treatment and monitor and improve the patients’ well-being. “This type of tool helps increasing the perception of care among patients and families, strengthening the relationship between them, the health care team and the organization,” says Alze Pereira Tavares, head of the medical team and of the Service of Palliative Care of Paulistano.

Tavares explains that the main goal of the assess-ment is verifying whether the needs of the patient and the family are being met by the healthcare pro-fessionals. “We deal with human suffering. To find out if we are acting appropriately, controlling the patient’s suffering, we have to ask the patient about it,” he explains.

Two indicators were considered for assessing the quality of care and the well-being of the patient: pain and shortness of breath. “Our goal is to control or improve pain and relieve the shortness of breath in at least 75% of patients in at most 72 hours after admission to the program,” says the medical coordi-nator of Paulistano. This means that if the patient has pain or shortness of breath on the admission to the program, the goal is that within three days, the pain is improved, ie, “on a scale of zero to four, where

zero is without pain and four means unbearable pain, the patient would report a maximum pain of 1, ie, mild pain” says Tavares. In order to control it, a questionnaire is applied soon after the patient’s admission to the program and reapplied on the third day. From this point on, the assessments are per-formed weekly. According to the head of the clinic staff, when the patient has a moderate to intense symptom, the patient will be assessed with a great-er frequency and the treatment is intensified with the aim of relieving the discomfort as quickly as pos-sible. He points out that the responses to the ques-tionnaire used by patients are important to determine the most appropriate treatment. “Thus, when the patient has some important symptom detected during an assessment, the staff will provide all necessary support. Upon the detection of a symptom, the team will treat it aggressively until it is controlled

Palliative care

Hospital Paulistano adopts a tool to measure the patient’s well-being

symPtom’s control


or relieved. The questionnaire applied to the patient is transcribed in a graph for each symptom and is attached to the patient’s medical record so that all professionals have access to the symptoms,” explains Tavares. According to him, from the results of these graphs, it is also possible to observe the evolution of symptoms over the course of the disease and estab-lish treatment strategies and goals to be achieved with the patient and family.

The palliative care service of Hospital Paulistano uses the Palliative Outcome Scale (POS) which pro-vides ten questions covering physical, emotional, social and spiritual areas as well as practical aspects of the patient’s lives. The Palliative Outcome Scale – Symptoms is also applied, which routinely assesses the presence and intensity of ten symptoms, includ-ing pain, shortness of breath, anxiety, nausea, vom-iting and loss of appetite. “Before applying the tool, we explain to the patient that the goal is to flaw-lessly assess what he is feeling, so that staff can assist him in the best possible way to overcome these difficulties,” said Tavares.

the resultsImplemented in August 2012, after a period of testing and adjustments on the application strategy, PROMs records 88% success in controlling pain, 86% success rate in controlling shortness od breath, 86% in controlling nausea and 82% in controlling vomiting on the third day of monitoring by staff (see figure). In addition to showing success on the control of many symptoms, the tool also points areas that need improvement. “We know that, on anxiety control,

for example, the result is 60%. Therefore, we need to improve this index,” adds the head of the pal-liative care service.

According to him, the implementation and con-solidation of the use of PROM allowed the identifica-tion and improvement in quality of care in palliative care services, since almost all eligible patients agree on joining the program. “We knew that this was an important aspect for the certification of the palliative care program in Hospital Paulistano because the Joint Commission International accreditation standards require that the services assess the needs of patients in palliative care based on validated tools, and that is the case of POS,” he adds.

According to Alze Tavares, attention to detail trans-lates into confidence and consolidates the relation-ship between medical and health care staff and the patient and family. “With the adoption of the tool, patients and family members realize that there is a greater concern of the care team with the patients, an extra attention. I think it’s a way of getting closer to patients and adding value to the care pro-vided by the staff”, he concludes.

R. Martiniano de Carvalho, 741 – Bela VistaSão Paulo/SPTelephone number: 55 (11) 3016-1000www.hospitalpaulistano.com.br


Since the Joint Commission International (JCI) accreditation in 2010, Hospital TotalCor (SP) has been improving its quality indicators. In 2011, with the requirements of the new JCI Standards for Hospitals, the organization initiated the Statistics and Accuracy Evalua-

tion of administrative and care indicators. Since then, the hospital has been measuring and monitoring the results obtained in a safer and more substantial way. “This measure is essential for making the right decision, since the calculated numbers become more reliable. It already shows good results, as evidenced in the care indicator Time of Extubation after Cardiac Surgery,” says Sandra Pereira, quality manager of TotalCor.

“Through comparative graphs between the months of December of the years 2012 and 2013, for example, we observed a reduction of 65% in the average time after cardiac surgery,” states the quality manager.

This means that when the organization discloses a data or an indicator, it has been validated by a statistician, including the accuracy of it. The goal is that, by standardizing the collection of information, when the team measures an indicator, they are sure that the data was properly collected. “It is essential to establish clear and transparent criteria on analyz-ing the data. It has to be an established path: how the data was collected; and where it was taken from so that there is no divergence on the numerator and the denominator on a second collection,” says Pereira. The next step is to identify who collected the data and what methodology was used. For the second collection, a person that was not involved in the pro-cess is selected. This person will collect the data fol-lowing this same path. The goal is to achieve results with minor variation. That is, lower than 90%.

quality indicatorsThe selection of the set of indicators monitored by the quality department of TotalCor is established by the managers of the indicators, the Quality Com-mittee and Quality Management. This makes the list of indicators multidisciplinary and multisectoral. A monthly meeting is conducted with the managers and the Quality Committee to present the results. According to the manager of Quality, about 30 indica-tors are discussed every month. The methodology consists in presenting the result and, when it is not within the expected range, developing a plan of action for that indicator.

For each indicator, there is a set of procedures that helps maintaining the accuracy of data and the reliability of information, ie, to disseminate and share the date, the following must be done: a Technical Sheet, in which all the indicator methodology will be directed; Statistical Validation; in which the collected data is submitted to a statistician for analysis; and Accuracy, which verifies the validity of the data in the source of information collection. On the evaluation of the care indicator Time of Extubation After Cardiac Surgery, the data collection was conducted through an analysis of the forms filled out by physiotherapists in the ICU, which documented the time the patient

reliaBle data

totalcor invests in improving the process of data collection


came to the unit and the time the extubation was performed. The Quality department monitored the entire collection process, and since the data was entered in spreadsheets, redid the calculation and compared the two results.

Once a year, precisely in January, a critical analysis of each indicator is conducted and, there-after, actions are planned for the indicator that was analyzed. The performance, historical series of the previous year, accuracy and statistical validation are evaluated. “Unlike the past, today we have to collect data uniformly and, once a year, the accuracy must be checked to verify if the previously agreed standards are being followed. Once a satisfactory result is achieved, a plan of action is developed” adds the manager.

According to Pereira, if, after accuracy, the results are lower than expected, it is necessary to fix and

then redo the process. “If we do not achieve a sat-isfactory result, we develop a plan of action, fix it, and after 90 days, we redo the accuracy,” she notes, explaining that the monthly accuracy is only per-formed when there is divergence on the behavior of the graph. The same process of repetition can also be generated in the statistical validation if any indi-cator is outside the curve. In this case, a root cause analysis is carried out. If, for example, in a particular month, there was an event peak, the Quality depart-ment carries out an analysis to really understand if there was a problem on the data collection or if there was any seasonal effect in the organization.

“When an indicator reaches its goal – and remains stable – it is forwarded to its department for mon-itoring and is not presented at the monthly Quality meeting. Annually, the Quality department evaluates new indicators with critical results to be worked with the Quality Committee,” describes Sandra Pereira.

Since the implementation of the process of statistical evaluation and accuracy of indicators, TotalCor started working with more accurate, correct and reliable information, favoring more uniform and standardized processes within the organization. It is like having a real portrait of what is happening within the organization. “I believe that a good point that JCI accreditation brought to us was the stan-dardization of the indicators, transparency and correct and safe data collection, because there is no way to ‘fake’ the information. We must indeed search for the information at the source, and col-lect it the best and most correct way possible,” concludes the Quality manager.

average time to extuBation after cardiac surgery (Hours)

Alameda Santos, 764 – Cerqueira CésarSão Paulo/SPTelephone number: 55 (11) 2177-2500www.totalcor.com.br


“The knowledge produced here since 1986 has rewritten the history of lymphatic filariasis.” The phrase may sound exaggerated or pretentious, but just half an hour’s conversation with Abraham Rocha, coordinator of

the National Reference Service in Filariasis (SRNF), which is part of the Research Center Aggeu Magal-hães (CPqAM) unit of the Oswaldo Cruz Foundation (Fiocruz), in Pernambuco, is enough to recognize that the clinical, laboratory and epidemiological contri-butions made by the organization, which operates in the areas of care, research and training of human resources and education, were, in fact, essential to the knowledge of lymphatic filariasis. The disease, caused by the filarial worm, a parasite transmitted to humans by the mosquito Culex quinquefasciatus, became a target of the World Health Organization (WHO) that aims to eradicate it by 2020, according to the commitment of endemic coun-tries such as Brazil.

SNRF, the world’s first tropical disease health service to be accred-ited by Joint Commission Interna-tional (JCI ) will spare no efforts and expertise to overcome the chal-lenge of eradicating the disease. After all, it was there, for example, where it was detected that the im-munofluorescence laboratory test used in areas endemic for filariasis as a criterion of cure had no scien-tific value, due the cross-reactions between filaria and other parasites.

The team also found that the adult worms, in case of male patients, are housed in the scrotum and that filariasis is not the direct cause of elephantiasis, as it was once believed, but that it opens the doors for the disease. Another finding was that the admin-istration of an annual dose of the standard filariasis medicine, used in group, for five years, is as effective as individual treatment, as it reduces the side effects of the drug and, consequently, increases adherence to the treatment.

All these contributions have strengthened the service, which has become nationally and interna-tionally recognized and in 2000 was pointed, orga-nizationally, as a national reference service by Fiocruz. Eight years later, it became a national refer-ence unit for the Sistema Único de Saúde (Brazilian National Health System). Accreditation, according to

the coordinator of the unit, was the final step to be achieved: “We realized we were mature enough to apply for the JCI in-ternational accreditation process. It was very important to the organization because we were already a center with interna-tional quality. We had been working with quality for years and going through the accredita-tion process would show us if we were respecting all the qual-ity and safety standards.” says Rocha, PhD in Sciences.

International accreditation granted in November 2011 showed the need for improvement and

more Quality and safety

accreditation reinforces international recognition of fiocruz research center in the fight against filariasis

Abraham Rocha, coordinator of the National Reference Service for Filariosis (SRNF)


inclusion of certain standards, not only in the clinical laboratory, but also in patient care, during outpatient care, and on Fiocruz-PE’s infrastructure with the only bank in the world that holds the Wuchereria ban-crofti species of the filarial worm. Around 500 patients are referred from other public or private health ser-vices to SRNF per year, says Rocha. These are people from Pernambuco, other Brazilian states and even from foreign countries, that are welcomed by a team consisting of 16 professionals and graduate students.

“With accreditation, came a commitment, espe-cially an organizational commitment, because it was a change that involved individuals from the cleaning staff to the director. Although we were in compli-ance with international standards, we had other standards to meet in order to improve quality of patient care and also for our staff. Before accredita-tion, cleaning staff did not know how to clean the laboratory according to the international standards and they were not intensively trained on safety and biosafety. In addition to that, there was no group of rescuers or fire brigade nor a system for detection and firefighting. Now, in addition to all these, we performed fire drills and provide educational lectures for patients and the community. The accreditation process provides safety for those coming to the or-ganization and for those who are already here”, con-cludes the SRNF coordinator.

Accreditation also promoted changes in the reg-istry of biological samples, registered in an electron-ic system, protected by a unique password for every single professional who accesses the software. The software enabled an automate control of samples that arrive in SRNF. “We had an electronic record but we realized it was necessary to include other

information to meet the requirements of the process, providing more quality and are safety. Each profes-sional can only add the information assigned to him in the medical record. That is, sonographers can only include information related to ultrasound; the urolo-gist can only insert information of his field of work and so on. A professional, therefore, cannot change the information included by a professional from another field of expertise,” explains Rocha, adding that the way to deal with the ultrasound equipment and other equipment of the organization was also changed to include systematic preventive and cor-rective maintenance, and not just annual inspections as previously established.

After accreditation, the organization implemented a minimum follow-up for patients who have some type of health problem other than filariasis. “If during care we detect that the patient also suffers from, for example, hypertension or diabetes, we refer him to an appointment with an expert. There is a tracer that provides information on whether the patient was treated appropriately by that expert,” informs the coordinator of the unit.

Other changes are underway. One concerns the creation of SRNF indicators: “We did not have this culture here. We are now discussing it because we believe that the process of quality is a process of maturing”, notes Abraham Rocha.

Centro de Pesquisas Aggeu MagalhãesAv. Professor Moraes Rego, s/n – Campus da UFPe – Cidade Universitária – Recife/PeTelephone number: 55 (81) 2101-2500 and 55 (81) 2101-2546www.cpqam.fiocruz.br


With an average of 6,000 emergency visits per month, Hospital Memorial São José (HMSJ), located in Recife (PE), has a strong surgical profile and around 700 surgeries are performed in the organization per month. With an overall

conversion rate of 4%, including adult and pediatric urgencies, the health care organization faces the dai-ly challenge of managing the inflow and outflow of patients in order to provide care appropriately, since patients with scheduled and authorized procedures need to be ensured that there will be available beds for them.

“Therefore, this is the starting point of out hospi-talization management con-trol,” observes the manager of Hospitalization and Emergency Unit of HMSJ, the physician Alexandre Cunha.

To give more agility and precision when controlling the flow of the admission sector, in 2013, the hospital developed a patient check-in service for patients with scheduled and authorized elective surgeries. In addition, staff members are available to the medical teams and pa-tients seeking authorizations, seeking to speed up these procedures. Once the surgery is authorized, our hospitality

team contacts the patient on the day before the scheduled date with the goal of clarifying doubts, as well as providing orientation about the time of the last meal, tests that should be brought to the hospi-tal and other information. We realized that many procedures were cancelled at the last moment by the lack of this type of attention”, says Cunha.

Another strategy adopted was to complete the next day’s surgical map next day until 5 pm of the previous day. This way, it is possible to accurately

visualize the next day’s agen-da. In addition to this action, a multidisciplinary group, con-sisting of physicians, nurses, hospitality and cleaning staff performs daily rounds at the end of each day to identify possible discharges for the next day. With these two mea-sures, in addition to the direct contact of the hospitalization manager with the hospitality sector, it is possible to know how many beds will be avail-able for the next day. “With these data, we can properly plan surgical admissions and see how many beds will be available for clinical admis-sions, mostly from the emer-gency department. Being accredited made us improve the process of patient care and organization management”, highlights Cunha.

managing admissions

Hospital memorial são José adopts a new process for admission and improves bed management

“with simple measures and good teamwork, it was

possible to achieve better results, with an increase on the

number of performed surgeries

and improvement on the occupancy

rate of the hospital, while improving the

quality of the service provided.” alexandre cunha, manager

of Hospitalization and emergency unit


pursuing resultsSince the adoption of these actions, HMSJ already managed to significantly reduce the number of can-celed procedures, which translates into improved financial performance of the organization, enhancing its credibility among their patients. “With simple measures and good teamwork, it was possible to achieve better results, with an increase on the num-ber of performed surgeries and improvement on the occupancy rate of the hospital while improving the

quality of the service provided,” ensures the man-ager of hospitalization and emergency unit.

According to the manager, the control of the flow is done through the interaction between the teams involved in the process of managing the flow of hospitalization. Combined with team work, there is a hospital management program that enables visu-alization of the occupancy of beds in the hospital. “This role is performed by the discharge team to-gether with the hospitality staff. It is a daily activity with the goal to plan the next day,” he says. After this, the hospital observed another issue: “The patients would often be discharged by the physician but the administrative discharge only happened hours later. The patient exit does not take more than two hours after medical discharge but during rounds, we ob-served that there were some discharges taking from 6 to 8 hours to be carried out,” he explains.

Once the problem was identified, the next step was the find out the causes. One of the main causes was the lack of communication between teams. The physician would authorize the discharge and leave the medical record in the nurse station. This way, the nurse would only see that the patient was discharged by the physician after a few hours. Only then, the nurse would call the administrative sector which would take more time to expedite the patient’s discharge. For us, that represented loss of quality,” he evaluates.

Closing the surgical map until 5pm helped solve the problem. “We know what is expected to end on that day, ie we know how many surgeries will be performed. We can see the hospital’s occupancy rate that is informed by the management system. Therefore, it facilitates the visualization of the sce-nario of the next day, with enough time to make a contingency plan if necessary” says Cunha.

According to the manager, in addition to this de-crease in the time of discharge, it was established that the patient could stay no longer than three hours in the emergency unit. “We have a 6 hours deadline to solve the patient’s problem. If I know we are full and a hospitalization was requested, I’ll go to plan B which is transferring the patient to another organiza-tion” he adds. “Our occupation goal ranges around 4 days. The bed turnover is important to make room for clinical patients – patients who will be hospitalized for administration of antibiotics for about 10 to 15 days, for examples,” Alexandre Cunha adds.

Av. Governador Agamenon Magalhães, 2.291 – DerbyRecife/PeTelephone number: 55 (81) 3216-2222www.hospitalmemorial.com.br


Recently, Karina Banhos, nurse of the De-partment of Quality and Risk Management of Hospital 9 de Julho (SP), has been re-peating three concepts very often: barrier, control method and contingency action. But she doesn’t mind repeating them when

necessary, because they are part of a program that is been implemented in the organization. The initia-tive aims to further ensure quality and safety to the multitude of clinical processes on the hospital routi-ne, through a mapping and risk management tool that identifies and seeks to reduce unexpected situ-ations that may cause problems for the safety of patients and professionals .

According to the member of the Department of Quality and Risk Management, the idea of reviewing the processes, considering the risks involved in it, arose from the need to analyze the processes on a preventive way and adapt them to the parameters of the Joint Commission International (JCI) Accredi-tation Standards. So far, she said, the program has been applied to the hemodialysis unit and the infu-sion center and is under implementation in the emer-gency room, inpatient unit and surgical center. It is estimated that, in August, all hospital departments will be involved.

The initial contact to discuss the program within each sector is a meeting between the quality depart-ment and the managers of that area, at which point they can list the critical steps of the ongoing pro-cesses. Then, a discussion with professionals di-rectly involved in every possible risk seeks to un-derstand what barriers are being put in place and which still need to be adopted. To minimize doubts, Banhos explains the difference between barrier – ie,

something implemented in the process to prevent a certain risk; control method, which is placed in order to check if a particular barrier is being adopted; and finally contingency action, a measure taken after the occurrence of the risk.

“We hear these professionals so that they tell us what to do to prevent those risks identified in those processes; ie, it is the team that develops the map. The goal is for them to see the process of their work within the map. It is a notably educational process.

risk management

Hospital 9 de Julho creates tool to encourage prevention


We direct it only to explain the concepts, because there is an initial difficulty in them”, describes Banhos. According to her, as the explanations are given, these professionals will identify and mention the problems. “We are mapping all sectors, from the scheduling central, which schedules surgeries, to the physician on the other end.”

developing the risk MapThe following steps are the preparation of the map, that is posted on a place with a great flow of sector staff so it can be easily seen; and staff training. Although the map is not placed on a location that permits easy visualization by patients and their families, the nurse recognizes that this can happen. The document contains important actions of preven-tion adopted by the hospital.

The nurse ensures that the following standards were taken under consideration during the map de-velopment: Quality Improvement and Patient Safety (QPS) of the Joint Commission International Accredi-tation Standards for Hospitals, which addresses risk management. “We used accreditation standards on the development of the map and the tool. They were closely observed during the development of the maps so we could see if we were meeting the re-quirements on risk management in a hospital unit. Standard number 11 is very specific when addressing the importance of an ongoing management program that identifies, prioritizes, reports, manages and in-vestigate risks” she adds.

Although is it still early to draw an evaluation, Karina Banhos adds that it is already possible to note the concern of the hospital regarding prevention. “We

realized that the barriers are implemented, but there are few methods of control” she says. During the implementation of the tool, for example, a situation was discussed concerning the referral from the inpa-tient unit to the operating room, where there was a need to strengthen the control of documentation check to ensure that all documentation required is at hand and belongs to the patient being referred.

“We noticed there is a checklist to verify the man-datory documents but we didn’t know the moment it was filled out and if it was always filled out. Now, it is established that it will be carried out on the exit door of the inpatient unit”, says Banhos adding that it was also established that the operating theater will generate semiannual non-compliances reports to un-derstand if and when the failure occurred.

Once the development of maps is concluded, the following step is the review, expected to occur an-nually, at which indicate it is possible to verify if the improvement actions pointed out were implemented. “The map indicates where the process is good and where it has to be improved This way, the manager knows where he should focus. The map is not a plan of action. It points out risks and ways to control these risks”, stresses the nurse of the Department of Quality and Risk Management of Hospital 9 de Julho.

R. Peixoto Gomide, 625São Paulo/SPTelephone number: 55 (11) 3147-9999www.h9j.com.br


Ensure patient information security during interhospital transfers. With this objective, Amil Resgate Saúde has adopted, two years ago, a new medical record form to be used in ambulances during transport of patients. The Transportation Form is a

single document that contains documented infor-mation generated from events and situations about the patient’s health and care provided. The document, now customized, is part of the patient record, enabling communication between members of the care team and therefore, enhancing continuous patient care. The procedure adopted for documentation in the medical record follows Joint Commission Interna-tional (JCI) standards.

The implementation of this new form already shows results. An example is the index of pain reas-sessment that improved 1.6% in a year; in December 2013, 98.9% patients were reassessed compared to 97.3% on January of the same year, a total of 2,196 forms evaluated. “The goal is to ensure the quality and safety of care for the patient being transported from hospital A to hospital B. Everything is dynamic, and several situations may occur in the ambulance during the transportation. On the other hand, the hospital that receives the patient has to be aware of everything that happened in hospital A and if there were any complications during transportation. This is a tool to ensure continuity of treatment and care and it is aligned with one of the chapters of JCI’s manual

safety and Quality

amil resgate adopts new medical record form ensuring more reliable information

INDEx Of ASSESSmENT AND REASSESSmENT Of PAIN (2013)


which addresses this subject,” notes Marino Pellegrino Guer-rier, medical manager of Amil Resgate Saúde.

According to the physician, the reassessment of these patient information also re-sulted in a care improvement because the vital signs are verified at the beginning, during the transportation and then, again, once it reaches the destination. “If the last verification is not carried out, for example, the patient may have a change in his condition and since he wasn’t reassessed, he might not receive proper care,” he says.

To develop the current form, Guerriero explains that the starting point were the forms used previ-ously in the ambulances. “We started with a printed form according to JCI’s indications” We developed several versions of it until we got to the best form regarding quality of the notes,” explains Guerriero.

customizing informationTo achieve a high level of adaptation and customiza-tion, specific fields were created for certain records such as Pain Reassessment, as well as its character-istics and fields for Reassessment of patient vital signs. The medical record is now divided into parts. In the first part, data such as patient identification, registra-tion of transport times, summary of information from transportation origin and informed consent are docu-mented. In the second part, data obtained during the

transportation such as patient history, assessment and reassess-ment of vital signs and pain, as well as notes from physicians and nurses are documented. The third part is filled in at the moment of the patient’s arrival at the desti-nation. “At start, it was difficult to develop this form. To achieve adequate compliance, we had to split the record into these three moments, and create specific

fields,” says Guerriero. The medical manager stresses that, at the time the team arrives at the transport origin, the first approach is performed in which several criteria are evaluated, such as vital signs, pain score and level of sedation (when applicable).

In addition to the index of pain management, the organization measured results regarding the com-pliance of the form completeness by physicians and nurses. In 2013, for example, of the total of 2,196 filled out forms, the index was 89.2% in January com-pared to 94.5% in December.

Yet as improvement action in order to ensure the confidentiality of information recorded, a safe was provided inside the ambulances, where the transportation forms are placed after the filling out. “The medical record is the document that contains all the details of patient care whether a hospitaliza-tion or a simple procedure. This information is con-fidential, and only patients and families are authorized to check their records. We did this in order to ensure the security of patient status information” adds the medical manager of Amil Resgate Saúde.

Alameda Rio Negro, 1.356 – AlphavilleSão Paulo/SPTelephone number: 55 (11) 4197-1001www.aeromil.com.br

“we started with a printed form

according to Jci’s indications.”

marino Pellegrino guerriero, medical manager of amil

resgate saúde


Those who see the hundreds of physicians walking on the corridors of Hospital Santa Paula (SP) possibly have no idea of how rigorous is the process for granting privileges so they can perform any medical procedure in the organization. The hospital provides

care for 100 thousand patients in the emergency unit and performs around 7,500 surgeries per year. Today, there are 1,800 registered physicians and, according to the organization’s leadership, all without exception, had to go through a number of steps to earn the right to be part of the clinical staff.

And the word ‘all’ is not just rhetoric, because even professionals who use Santa Paula sporadi-cally to perform, for example, a surgical procedure requested by the health insurance, or even those who are appointed by members of the clinical staff of the organization, go through an extensive pro-cess of privileges granting, which is nothing more than the permission of the Executive Board so the professional can perform procedures in the orga-nization after checking the data regarding their training and titles.

“No physician will enter here if not properly registered,” emphasizes Raphael Einsfeld Simões Fer-reira, medical director, explaining that the total num-ber of physicians with active registration is currently around 800. “The others are professionals who per-form procedures sporadically,” he adds, noting that such requirement is due to the required attention regarding quality of service and safety of patients.

According to Ferreira, the process of granting of authorizations has been gradually improved since 2010 to increase the degree of reliability in relation to clinical staff, as well as meeting the requirements

established by the Joint Commission International (JCI) for accredited hospitals. In order to do this, Santa Paula went beyond the physical functional records where every data of every clinical staff member is located. The organization implemented an electronic record accessed by login and password. In the elec-tronic record, all the physician’s data is updated, such as privileges (privileges granted), annual performance evaluation and curriculum vitae.

Each physician may request different privileges. The granting of which will depend on the evidence of their professional qualifications. When the profes-sional intends to eventually perform only one proce-dure in a given patient, the authorization will be temporary. If the professional wishes to join the medical staff, the granting of the privilege will be permanent and revalidated every three years.

the grantingThe first step to have privileges granted is to request a registra-tion stating what the physician wants to perform in the hospi-tal, and then submit documents such as identification, medical school diploma, registration in the Regional Council of Medi-cine (CRM) and titles in the area of expertise. Once the hospital receives these documents from the professional, the leadership of the hospital verifies if the

validation of tHe medical staff

Hospital santa Paula creates a system that qualifies physicians to work in the organization

Raphael Einsfeld Simões Ferreira, medical director


CRM registration is active and if there is any ethical issue that discredits the physician. The authenticity of all documents is verified with the sources. “This is necessary because, unfortunately, there are cases of falsification of documents,” said Ferreira.

After this verification process, which includes re-viewing the credentials of the professional before the privileges are granted, the professional is inter-viewed by the medical leadership, where Santa Paula’s bylaws and the Code of Ethics and Conduct are presented. If the professional accept the terms, he will then receive permission to act in the organi-zation. From there on, the focus becomes another: ensure good performance of the professional in the hospital routine. In order to do this, the medical direc-tor developed a series of performance indicators, around 20-30, that may vary according to the spe-cialty, in order to evaluate the physician’s performance considering the care quality, continuous updates and monitoring of results compared to medical literature.

The indicators of each professional are evaluated annually. If a physician is below the established target, he is called by the leadership to discuss this fact and is referred to training. The hospital ex-pects that the professional’s performance improves. Otherwise, the privileges may be withdrawn par-tially or completely. “If for three consecutive years, the situation does not change, the professional is automatically dismissed from the organization,” ex-plains the medical director.

Regarding the adopted criteria, Ferreira believes that the primal criterion was the creation of barriers to entry through changes on the granting of privi-leges and centralization of the process on the medical director office: “In the past, the physician

had facilitated access because there wasn’t such a comprehensive requirement. We are responsible for any event that happens to the patient. To share responsibilities, it is essential to know the qualifica-tions of the professional. “

The medical director says the JCI accreditation standards for hospitals guided the changes in Santa Paula: “We had to meet the requirements of the stan-dards,” says Ferreira, noting that the changes resulted in improvements. As a result of the new requirements for admission of clinical staff, there was a large re-duction in the number of registered professionals, whose numbers fell from 3,500 to 1,800, with no impact on the rate of hospital occupancy.

“When you start to measure the performance of individuals, some turn away because they do not want to be evaluated and others are excluded be-cause they do not meet our criteria. This ensures more quality and safety of the care provided to pa-tients. It is important not to let the indicator worsen and to be pro-active. What I want as Director is not to be charging individuals, but to assist everyone on constant improvement” he concludes.

Av. Santo Amaro, 2.468 – São Paulo/SPTelephone number: 55 (11) 3040-8000www.santapaula.com.br


Improve patient safety and satisfaction. Focusing on these two needs, Hospital Santa Joana (PE) has been conducting a series of implementations in the multi-emergency unit such as investments for designing new physical spaces and remo-deling and expansion of other areas; expansion

of medical and nursing staff; and adoption of tools that optimize patient safety. With these actions, the organization has successfully reduced the turnaround time for providing care to patients arriving at the emergency room. According to Fátima Sampaio, manager of multidisciplinary care of hospital Santa Joana, the delay of medical care was one of the main patient complaints.

“With the increased demand for care, we had to make a general change in both physical area and flow of care; and implement some innovations to improve customer satisfaction and safety of care,” explains Sampaio. One of the changes was the creation of an online monitoring tool in which the status of the patient is recorded in the electronic medical record. “With the adoption of PID (Intelligent Patient Identification), you can manage the entire flow of care” she says.

The care manager also explains that a group of nurses performs the patient’s initial assessment based on a priority protocol once the patient enters the emergency room. The patient will then be referred

tecHnology at safety’s service

santa Joana Hospital is restructuring the physical area and the care processes on multi-emergency room and improves care


to the appropriate area according to the screening: red area is where patients are more critical and need more resources. Intermediate pa-tients stay in the yellow area. The green area hosts patients without risk and that could have used the outpatient service. “As the emer-gency room is divided in these three areas, each area should provide all that the patient needs. For example, patients often only need bandages: then the patient is sent to a specific area for that type of care” says the care manager. Also according to Sampaio, these criteria were listed for all specialties in accordance with the signs and symptoms the patient shows. Only then, the patients are referred to a physician within each area. To record and monitor all appointments, the electronic medical record was implemented.

electronic record When the patient arrives at the appointment, the record filled out during the patient’s initial assessment is accessed and the physician reads the nurse’s notes. After that, the physician provides care to the patient and meanwhile, the patient status is shown on screen so that the area coordinators can have access to this information. “Professionals share information so there is no delay on the initial care or on patients’ reas-sessments. There is a specific color for every status (waiting for care, waiting for tests and waiting reas-sessment) and waiting time”, ensures the care manager. She explains that the patient receives a

white label, for example, but it might be replaced during the care provided: “The white ball turns green when the patient is being cared for. If the patient waiting time exceeds the time planned, the status turn from green to red. The new flow allowed greater agility as well as better process monitoring.

More safetyWith this new restructuring of the care process, Sam-paio says it was possible to have new indicators: time and appointment resolution, conversion rate and pa-tient satisfaction. A radio frequency monitoring pro-

cedure was implemented (RFID system), allowing identifica-tion and monitoring of patients through a bracelet with a bar code received upon arrival to the hospital. This step is under implementation by the hospital. “There are radio frequency an-tenas in the emergency room informing where the patient is and the TV shows a map of the area, facilitating the localization of the patient inside the emer-

gency unit. Thus, we can estimate how long the pa-tient should stay in each area” she says.

The care manager rates that this restructuring has brought more benefits to the processes already implemented in hospital: “There were no changes in the protocols adopted over a year ago to meet the international safety goals recommended by the World Health Organization and by Joint Commis-sion International. We just improved the protocols so the answers would be more effective. Conse-quently, the processes became more present and effective” she explains.

According to Fátima Sampaio, the results appeared a few months after the restructuring and it was pos-sible to verify the improvement of the time for care and patient satisfaction. “With an average of 7,000 visits/month, our multi-emergency room, which of-fers nine specialties and runs 24 hours a day, shows a growing trend in the service curve. Our goal is to provide the patient an agile service, with safety, using quality processes in which the patient care safety and resolution is backed by accreditation.” concludes Santa Joana’s care manager.

R. Joaquim Nabuco, 200 – GraçasRecife/PeTelephone number: 55 (81) 3216-6666www.santajoanape.com.br

“The new flow allowed greater agility as well as

better process monitoring.”

fátima sampaio, manager of multidisciplinary care


Work so the patient can return home as soon as possible, ensuring the best care and respecting all safety conditions. That is the goal of care planning, that goes beyond a close contact between the clinical staff,

patients and family members, as Hospital Alvora-da (SP) has already noted.

In September of last year, the organization cre-ated multidisciplinary teams – consisting of a physi-cian, a nurse, a physiotherapist, a speech therapist, a dietitian and a nutritionist – in order to early iden-tify patients with potential for long-term hospital care, ensuring all care necessary to reduce the length of stay to the necessary period of time. The organization considers long stay inpatients those who stay hospi-talized for longer than 14 days.

According to the General Practice coordinator Marcos Sanches, when the patient matches the profile for long-term care during the treatment scheduling performed at admission, the multidisci-plinary team will focus on care practices to try to discharge the patient as soon as possible, with safe-ty, so that care be continued on the post-discharge period. To do this, the organization manages the protocols for the prevention of pulmonary aspiration, VTE and early mobilization.

According to Sanches, before the creation of the multidisciplinary teams, the average monthly rate of beds occupied by long-stay patients in Alvorada reached 20%. After the interventions, the indicator decreased to approximately 13%. The reduction, adds the Coordinator of General Practice, can be partially explained by the patient’s family education about the life changes resulting from the pathology, that

is carried as soon as possible. “Since the first approach, the team tries to assess the level of understanding of the family regarding the pathology. At this mo-ment, all team works together: if the patient uses a tube, the dietitian will provide instructions on how to buy or prepare the food; the nurse will talk about how to handle the tube; the physiotherapist will provide instructions on care regarding respiratory and motor issues; and, when necessary, the support of a psychologist is requested,” he explains.

care Planning

Hospital alvorada develops method to reduce the number of long-stay patients


other indicatorsCoordinator of Hospital Alvorada’s ICU, Céu Cordeiro notes that the monitoring of long stay patients allows actins on other fronts for it impacts indicators such as hospital-acquired infections, hospital-acquired pneu-monia, early rehospitalization and ICU hospitalization. According to her, the implementation of protocols, such as pulmonary aspiration and early mobilization, with the support of multidisciplinary teams, has enabled a relevant reduction of referrals of long-stay patients to the ICU: “We noticed that although the protocols were already adopted by the hospital prior to the long stay teams, they were often segmented. That changed with the interaction between the mul-tidisciplinary teams,” says the ICU Coordinator.

Education services to improve Care Quality and Safety for Alvorada’s accreditation process helped the interaction of professionals within the teams, Cordeiro points out. She adds that the changes in care were performed according to the standards of assessment of patients (AOP), access to care and continuity of care (ACC), care of patients (COP) and patient and family education (PFE), listed on the Joint Commission International Accreditation Standards for Hospitals manual. “Thereafter, the teams began working closer together, and this supports comprehensive and con-tinuous care. The implementation of the protocols also helped because with the standardization of care, arguments stopped,” she says.

optimizing bed turnoverWith greater efficiency and improved outcomes of dehospitalization of long-stay patients, there was a reduction in the average length of stay from 4.9 to the current 4.2 days. This action represented an in-crease of 41 admissions per month, considering the 80% average occupancy rate in Hospital Alvorada.

“Given the current shortage of hospital beds, we achieved a major advance by streamlining and improving outcomes, leading to improved quality in patient care, cost optimization for the payer and a better working environment for the multidisciplinary teams,” ensures Fernando José Pedro, technical di-rector of the hospital.

montHly average

Av. Ministro Gabriel de Resende Passos, 550Moema – São Paulo/SPTelephone number: 55 (11) 2186-9900www.hospitalalvorada.com.br


“Unfortunately, there is nothing else we can do”. The sentence, rendered by the physician in an impossibility of cure may sound to the patient or their family not only as a death sen-tence, but also a failure of medicine,

although healthcare professionals can still do a lot for terminally ill patients. This is what palliative the-rapy is, a type of care which is being increasingly adopted by hospitals and is already consoli-dated in Hospital de Clínicas de Porto Alegre (HCPA), an educa-tional unit of the Federal Univer-sity of Rio Grande do Sul (UFRGS).

The approach consists of care that proposes to increase the quality of life of terminally ill patients, as well as their families, through the control of symptoms, pain relief and treatment of physical, spiritual and psycho-social issues. It was first heard in the corridors of HCPA in 1985, brought from the first Latin American Congress on Palliative Care by the hospital’s physicians and nurses and was soon imple-mented to patients with neo-plasms. It gradually gained ground, and in 2006, the conclusions of the study group on the subject, consist-ing of nurses and students, led to the creation of the hospital’s Center for Palliative Care.

Since then, it gained more prominence in HCPA and, in 2012, the Palliative Care Program was created,

whereby the new approach, previously only for patients with advanced cancer, was extended to ter-minally ill patients suffering from other pathologies. Thereafter, in addition to the team who works di-rectly with neoplasm care, multidisciplinary groups, consisting of physicians, nurses, psychologists, physio-therapists, pharmacists and social workers provide assistance when requested.

“When we note, for example, that the patient is under condi-tions to be discharged, we pro-vide clarifications on which are the necessary care to be pro-vided at home.” details the phy-sician Lúcia Miranda dos Santos, head of the Pain and Palliative Medicine Service of HCPA which, this year, started to include the Center created in 2006.

The job requires full dedica-tion, Santos notes, highlighting, however, that obstacles were once much more difficult in health care services. Previously, it was not uncommon to hear cases of patients who went to medical appointments, and the physician had said something like “there is nothing more I can do

for you”, recalls the doctor, telling that even in HCPA, the changes came slowly: “It took great efforts to change this culture of care around the terminally ill patient and show the expert that although he can no longer intervene, he can seek professionals of the palliative care team in order to offer better quality

Palliative care

Hospital de clínicas de Porto alegre consolidates differentiated care to terminally ill patients

“when we note, for example, that

the patient is under conditions to be discharged,

we provide clarifications on which are the necessary care to be provided

at home.”lúcia miranda dos santos,

head of the Pain and Palliative medicine service


of life to the patient. But we cannot change the natural course of the disease.”

The caveat of the coordinator of palliative medi-cine service is important because, according to her, family would mistake palliative care with eu-thanasia, when, in fact, the goal is not to prolong life or hasten death. There are family members who still don’t understand. It usually happens when the irre-versibility of the condition is very recent. We then need to repeat the meaning of palliative care very often,” she explains.

respect to rightsThe orientation, moreover, is a requirement of the chapter on Patient and Family Rights of the Joint Com-mission International Accreditation Standards for Hospitals. Nurse Henrietta Maria Kruse, advisor of the Center for Palliative Care of HCPA, explains that

accreditation was very important for the hospital: “By analyzing the standards, the leadership concluded that we needed to develop a program and therefore have a clearer policy on terminally ill patients. We designed the program due to accreditation.

It’s hard to put patients at end of life as an im-portant agenda. And accreditation helped us on that.” For example: HCPA created a group of spiritual care to meet the religious needs of patients and their family members as a way to meet the requirements of the standards. “We have a list of representatives of various religious beliefs who can be called accord-ing to the wishes of the families” Lúcia Santos adds.

Listening to the patient, family and health care professionals is a relevant point to consolidate the process. Kruse recalls that many years ago, the hos-pital conducted a survey with severely ill patient’s family members and another one with staff. The first group replied that to be best served, it would be important to have a place in the hospital where they could heat food and bath.

Given the results, the Center for Palliative Care was created in an exclusive physical area, with seven beds, where family members are entitled to free meals. “The family is also very important in this approach. One of our roles is to prepare the family to stay at home and also for mourning. As our unit is intended for public health care service pa-tients, staying home is often a problem due to lack of financial resources. Therefore, we noted that these patients die more often here than at home. Some think that hospital care only works when the patient is cured. But the truth is that the process of death and dying is an inherent condition of life and humanized care in this stage is part of the qualified service an organization must provide” adds the Center’s advisor.

The survey with professionals revealed that more than emotional support, they would like to have access to training. Hence, the Palliative Care Service conducts biweekly meetings. “We seek to engage the whole population in contact with health care in the hospital. And many students also participate because we are a teaching hospital” says Lucia San-tos, remarking that HCPA is now preparing for a new stage regarding palliative care: “Ensuring this type of care for all patients that require this service and are served by the Palliative Care Program, not only the ones suffering from neoplastic diseases” says the Head of the Pain and Palliative Medicine Service of HCPA.

R. Ramiro Barcelos, 2.350 – Santa CecíliaPorto Alegre/RSTelephone number: 55 (51) 3359-8000www.hcpa.ufrgs.br


Hospital São José (SP) adopted a tool that allows anticipating possible failures: Failure Mode and Effects Analysis (FMEA) – tool that analyzes modes and effects of failures in order to prevent and anti-cipate risks. Since its implementation in

June 2013 in the Oncology Service, the department has been showing positive results. The steps of prescrip-tion analysis, preparation and dispensation of chemotherapy medication, for example, were the steps in which there was a reduction of risk, based on a matrix that assesses severi-ty versus occurrence versus detection. The matrix is ap-plied at the beginning and at the end of the process, once the improvement actions were implemented.

The pharmacist Márcia Vila-Real, Quality analyst of the hospital, believes there is already a reduction of short and long term risks. According to her, the percentage of risk reduction is 14.3% on the prescription analy-sis step; 5.1% on the chemotherapy medication preparation step; and 11% on the dispensation step. “For each step, we estimated a value of initial risk and after implementing improvements, we calcu-lated the final risk value and then measured the risk reduction. We still need to complete the steps re-lated to the change in physical structure and change in the computerized system,” she states. The next

process to be modified will be the manual checking that, according to the pharmacist, requires triple check.

The decision to implement the FMEA in the flow of chemotherapy was taken from the results of an inventory of threats, mapped in all sectors of the organization. Vila-Real tells us that based on this inventory, a risk matrix was defined and they came

to the conclusion that the process involving the medi-cation flow was the process that presented greater risk, possibly compromising quality and patient safety. “Within the overall flow of medications, we identified that the most important pro-cess – from risk reduction’s point of view - was the pro-cess of chemotherapy,” she notes, adding that chemo-therapy is an important stra-tegic area for the hospital which is focused on oncol-ogy, leading to a direct im-pact on patient care.

According to Vila-Real, in order to implement the tool, the organization created a schedule that involved care teams involved throughout the process of chemotherapy, including physicians, nurses and pharmacy, and clinical areas such as engineering and maintenance, among others, that could have, within their individual processes, influences on outcome of chemotherapy. Thereafter, a plan of action was developed for the phases identified as those with higher risk.

reducing risks

Hospital são José adopts a system for anticipated risk analysis on the chemotherapy process

“the aim of the tool is to work

preventively by identifying the

failure mode that seems to be

invisible in the process.”

márcia Vila-Real, Quality analyst


resultsSince the implementation of FMEA, what is been observed in the organization is greater safety in the chemotherapy process, reflected by the number of adverse events related to this sector. “The tool en-courages us to work proactively, identifying that one failure mode that appears to be invisible within the process, always focusing on continuous improvement” says Vila-Real. “Accreditation granted by the Joint Commission International is important because it is what drives us to pursuit this continuous improve-ment. And FMEA matches this scenario for it works preventively,” she adds.

R. Martiniano de Carvalho, 965 – Bela VistaSão Paulo/SPTelephone number: 55 (11) 3505-6000www.hospitalsjose.org.br

This improvement in management of quality and patient safety is also a reflection of a greater involve-ment of the multidisciplinary team since the adoption of FMEA. “The way the employee can contribute to the constant pursuit of quality management and pa-tient safety improvement is another positive aspect of the system implementation,” says the quality analyst. Another data that Vila-Real points out is regarding the low records of events related to the chemotherapy process in the hospital, which, she states, shows that the process is safe.

To ensure the effective implementation and analysis of this tool, the Quality Committee monitors the action plans developed with the staff through monthly meet-ings. “When we develop a plan of action, we begin to monitor the tasks to be performed and verify their effectiveness by validating what was implemented and assessing if it really brought improvement to the step identified on the plan,” says Vila-Real.

According to the Quality analyst of Hospital São José, although the steps and the process are safe and double or triple checks are carried out by different professionals, the next step is to computerize the entire system in order to further increase the accu-racy of this risk analysis: “We also identified that the environment in this manual process can become flawed, fragile, because of the professional’s atten-tion. We understand that computerization is important for us to achieve an even better result.”


Hospital Dona Helena (SC), that will cele-brate its centennial in 2016, was granted with the gold seal of Joint Commission International (JCI) on April 23rd, becoming the only organization in Santa Catarina to be accredited by the international

organization. The pursuit of international accreditation began in 2008, when the hospital board decided to adopt the strict standards of JCI. “The challenge to always pursue excellence, together with the identity of concepts and criteria adopted by Hospital Dona Helena and required by JCI was one of the main re-asons for opting for international accreditation,” says José Carlos Serapião, coordinator of the hospital accreditation process.

During the process to achieve international accreditation, the hospital took a number of actions to strengthen the culture of quality and safety. The first was to create the Quality Management Com-mittee (CGQ). Composed of a multidisciplinary team, the committee was responsible for developing activities and producing documents that supported the staff in the organization in pursuit of the seal. Other committees were formed subsequently, such as the Palliative Care Committee (CCP) and the Risk Management Committee (CGR). The first one aims to establish a culture of end-of-life care, facing death as a natural process. The second is responsible for identifying points that can lead to problems, suggest ways to prevent adverse events and implement safety standards.

According to the nurse Micheli Coral Arruda, coor-dinator of the Integrated Management System (SIG), “the benefits of accreditation were many. It led us

to adopt some processes, such as management of pain, which we did not have and also intensify others such as hand hygiene, with the goal of reduc-ing infection rates. In addition to that, we expanded actions related to prevention of falls by identifying patients with colorful bracelets. Today, we offer a much safer environment for all those in the organiza-tion. These are relatively simple processes that in terms of quality and safety provide significant results.”

acHieving accreditation

Hospital dona Helena is the first organization in Santa catarina to be granted with Jci’s gold seal of approval®

Carlos José Serapião, Maria Manoela dos Santos and Micheli Coral Arruda


team workIn the opinion of the SIG coordinator, during the six years of work to achieve the JCI seal, Dona Helena underwent changes that contributed to the improve-ment of processes and directly impacted on patient care. “All actions implemented were important to ensure better patient care. I highlight the expansion of our workforce, with the inclusion of a clinical phar-macist. Among other duties, this professional has the task to avoid errors in the prescription process and drug interactions,” she notes.

For Serapião, the engagement of the clinical staff was essential for the changes on the processes. The implementation of the Clinical Protocols Management, for example, helped to guide clinical practice, stan-dardizing the processes of care in diverse areas such as pediatric emergency, anesthesia and neonatal ICU, and also reduce risks, primarily those associated with decision critical steps. “The goal is to expand the Clinical Protocols Management for the largest pos-sible number of specialties. Ideally, all physicians provide the same service with the same quality. The implementation of this protocol sparked a new look on the provision of clinical care,” he ensures.

expansionIn the same year that the pursue of international accreditation started, Hospital Dona Helena began a process of expansion with the construction of the Clinical Center, a building of 11 floors and 26 thousand square meters. There, among other sectors, are located the Neurology Service, the Center for Ortho-pedic Diagnosis, the Center for Integrated Services to

Women, the Department of Oncology and Ambula-tory Surgical Center (CCA). In addition to that, the unit has recently opened the eighth floor with 37 new inpatient beds.

“The accreditation seal was granted to us only two months ago. That is, we do not yet have numbers to measure the results achieved. But we can already notice a significant reduction in events related to the decrease on infection rates and high alert medica-tions, for example. We have already started the analysis and data tabulation process. I estimate that, in six months, we will have the first results. We know that the improvement must be continuous and not only momentary. Maintaining the seal is as important as achieving accreditation. The pursuit of excellence can never have an end,” concludes Micheli Arruda, noting that, out of 1,181 elements assessed by JCI, 98% were deemed in compliance.

Rua Blumenau, 123 – CentroJoinville/SCTelephone number: 55 (47) 3451-3333www.donahelena.com.br

Documents

Healthcare Accreditation