Perception of Stakeholders on organizational performance in a Unified Health System hospital (100% SUS) with Level III Hospital Accreditation, Serra Gaúcha

The objective of this study is to identify the perception of stakeholders in relation to organizational performance and innovation after the Hospital Accreditation of Hospital Geral de Caxias do Sul – RS. The discussion points were aspects of organizational performance, Hospital Accreditation, and innovation in health services. As for the methodological aspects, applied research of an exploratory qualitative nature was adopted through in-depth interviews with stakeholders. The results showed that Hospital Accreditation contributes to the awareness and systemic view of the parties. It demonstrates that certification promotes learning, adding value to the lives of those involved, as well as bringing recognition from the society as a quality and creditable service, seen as a reference for other hospitals, especially for those who depend on public resources. A perception related to financial sustainability as well as a category of simultaneous action stakeholders (simulta-neous action of external and internal stakeholder in a teaching hospital activity) were also identified.


Innovation in Health Services
The definition of innovation in health is the intentional application of ideas, processes, products or procedures that are relevant to the unit that adopts them and at the same time benefit the individual, group, or society in general (Costa, 2016). For Thakur et al. (2012) innovation in health services is the adoption of best practices that ensure safety and the best results for the patient, in addition to positively affecting the performance of the organization. Porter and Teisberg (2007) understand that the ideal is to strategically seek innovations that increase the value for the patient (result obtained by invested capital) along the service delivery chain having a holistic view of the process.
Health organizations pursue six purposes: treatment, diagnosis, prevention, education, research, and access, and it is important to map the different stakeholders involved (COSTA, 2016). At the heart of healthcare innovation, we find the needs of patients and healthcare professionals, as well as providers. Hospital Accreditation considers all agents involved in the evaluation process, on performance being continuously improved, especially in the relationship between sectors, generating a systemic view for the best financial and service result.

Methodological Procedures
Exploratory qualitative research was carried out, with interviews between the months of November 2019 and January 2020. In total, there were two hours and forty-seven minutes of material recorded in electronic media.
A semi-structured research script was used, approved by specialist doctoral professors from the Graduate Program in Business Administration at the University of Caxias do Sul. The document has 5 blocks, and the questions were chosen in order to identify a relationship with the categories: Learning (3 questions), Credibility (2 questions), Resolution (2 questions), and Humanization (1 questions). Finally, in the fifth block (1 question), the questions are related to the interviewees' perception of the General Hospital.
External stakeholders (8 people) were selected, considered as clients. The classification of external stakeholders was in numerical sequence, as a way of preserving the identity of the participants. Respondents have knowledge in relation to the service provided by the organization, managers, and representatives of public health agencies in the State and the municipality. They are academics from the University of Caxias do Sul with degrees from three different areas and resident physicians, seeking distinct medical specializations. The collected data was compiled through content analysis. Table 1 shows the list and interviewed Stakeholders. Source: Drafted by the author, 2021

Research Object
The General Hospital of Caxias do Sul offers 100% care to users of the Unified Health System (SUS). Through an agreement signed between the State and government, it serves more than one million, two hundred thousand inhabitants, from the 49 municipalities of the 5th Regional Health Coordination of Rio Grande do Sul. It offers assistance in different specialties, has 237 hospitalization beds and a High Complexity Unit for Oncology.
UNACON offers adult and pediatric oncology and hematology services, oncology surgery, and radiotherapy.
Since 2018, it has Hospital Accreditation Level III -Excellence, National Accreditation Agency (NAA).
The funds of the hospital come from the municipality, the State, incentives from the Federal Government, through the Ministry of Health. It also counts on the support of the community in more than 50 humanization projects, whose resources are reverted to investments in innovation to provide improved patient experience when seeking treatment.

Perception of Hospital Accreditation and learning
The first block presents the answers related to the understanding of stakeholders regarding Hospital Accreditation and, consequently, the learning generated from said certification. "... it is a mechanism to build loyalty and revisit work, administrative or care processes, [...] in this scope of accreditation, it visits the process from start to finish..." (SE2) "I have heard it would be like a grade that is provided to the hospital regarding quality." (SE3) "...accreditation is a major goal to be achieved, a link between teams, sectors, to achieve goals and make the hospital move forward." (SE4) "when accreditation happens, everything has to be working perfectly, everyone goes after everything so that everything is within a standard, it is a single process...." (SE5) "...a body that regulates the standard to which the hospital is included, depending on its structure and the services provided." (SE6) "a way to improve the hospital, for it to improve the service provided before the bodies that govern the hospital." (SE8) Thus, it is understood that Hospital Accreditation is related to the standard of processes and procedures that qualify the provision of health services. It was identified that the perception of the respondents is related to the assessment of the process and activities performed in the hospital, with the objective of improving the efficiency of the service, improving care, assistance, and administration. Among the answers, to explain their understanding, they used as reference the ISO 9000 (technical standard used as industry quality certification) and explicitly used "Hospital Accreditation is the ISO of Hospitals".
According to Dutra (2009), when the company develops, people develop, and those, when they develop, do the same for the organization. The professionals who make up the company are directly responsible for its performance. The second question seeks to identify whether stakeholders know the level of accreditation and how representative it is for public health.
[...] at level 3, but as we do not follow it, for public health, it represents an institution focused on registration and information, documented, registered and validated work processes... for public health, through these records, you can know what really happens... (SE2).
"level 3 and it demonstrates that it is a quality hospital, also referred to by the population in the region..." Stakeholders' perception points out that the impact on society and the representativeness for public health is knowing that the institution provides a free service and is being leveled, accredited with the best existing performance in the evaluation of the national market. This result is of great importance for both the hospital and the population because the more engagement you have with patient safety and hospital standardization, the better the result for the population involved. It demonstrates concern in improving processes and equipment and in seeking resources to better serve the user. Some respondents were unable to explain how representative the fact that there is a hospital with Level 3 Accreditation in the community is for public health.
Still on learning, we sought to identify whether Hospital Accreditation aggregated learning or benefit to an

Perception of Stakeholders on organizational performance in a Unified Health System hospital (100% SUS) with Level III Hospital Accreditation, Serra Gaúcha
individual or entity.
" [...] as an integral part of this process, I believe that I could participate more, ... maybe this work can be a bridge between the Accreditation, its efficiency in the hospital, and the fact that it can take this culture to other SUS providers…" (SE1) "It didn't aggregate because we don't participate, unfortunately. If we participated more actively in the accreditation process, it would have." (SE2) "the better the service is accredited, the better it is as a reference in general. It is a reflection of higher quality; therefore the professionals are better and this impacts my training, my technical learning positively..." (SE3) "... I graduated in Pelotas, I had never heard of this issue of accreditation, the issue of hygiene, ... the hair tied back, earrings, rings, the smallest things... I didn't notice the day to day details and it does make a difference." "Since the accreditation, some processes have been modified and this ends up showing some points that were not working properly, and then it starts to make sense." (SE5) "... I believe that there are areas with more standardized behaviors than others, I identify that it has not generated learning, because for me learning comes from different areas..." (SE6) "Of course, I was in the ICU during the Accreditation period and I learned a lot, I didn't understand much about it back then, but you get knowledge... and it all adds up..." (SE7) "Yes... seeing the patients brings us peace of mind that they are being well attended, the organization, we feel comfortable, it benefits the patient, the employee and the students..." (SE8) The representatives of the Municipal and State Health Departments, apart from not aggregating to learning, believe that some deficiencies that exist in the regulation of patient access to the hospital could be improved.
It is important to highlight that, despite not identifying learning, all external stakeholders perceive the relevance and quality of the services provided by the General Hospital.

Credibility Perception
With the objective to verify the perception of stakeholders in relation to credibility, that is in its turn related to financial issues, through accountability and availability of support in cases of fundraising, considering involvement in order to influence public or private agencies. Credibility is considered as one of the variables that make up the image and reputation; the image is related to the concept about someone or something presented or projected by an audience, associated with the perception of veracity, acceptability, honesty, and public trust related to a piece of information.
In this block, the following question was directed to the interviewees: What is your perception regarding the accountability and investments in the HG? Did Hospital Accreditation influence this process? In organizational behavior studies, for example, credibility is treated differently compared to economics studies. While in the latter, credibility acts as a variable that helps economic agents to better predict the actions of monetary policy, in the former, it plays an important role in the establishment of trusting relationships reducing the costs related to its maintenance with the various stakeholders of the organization (Fox, 1974;Montes, 2008).
The perception of external stakeholders is favorable, as it is possible to check the application of resources in investments in equipment and structural improvement in the services offered. Despite the form of funding, there is transparency and stakeholder involvement through dissemination and delivery of the improvements developed. However, it is worth noting that the representatives of the State and the Municipality have the perception that the rendering of accounts could be more detailed, mainly due to the hospital being considered regional, and for many times not being able to provide service spaces for the public in the region. According to Eisend (2006), credibility is related to the individual perception of the truth about certain information, characterized as a multidimensional concept that acts as an instrument for evaluating information, a source or a transmitter regarding honesty. Still according to the author, there are three factors encompassed in corporate credibility: veracity; competence; agility.
Another relevant factor to consider is that some stakeholders identify that the hospital's credibility is influenced by Hospital Accreditation. It is also important to consider the fact that it is linked to a University which has been operating for more than 50 years in a significant manner for professional development and health for the community.
Still on credibility, at this stage of the interview, the question directed to stakeholders was: Would you direct resources or influence public or private agencies to direct resources to the General Hospital? Comment. "I would call someone else to invest, because it ends up adding much more than just one person investing. To be able to bring a better service to the local community and the region, not only in some sectors, ..." (SE8)

Perception of Stakeholders on organizational performance in a Unified Health System hospital (100% SUS) with Level III Hospital Accreditation, Serra Gaúcha
With regard to directing resources, considering public and private bodies, or as an individual, through projects, all stakeholders believe in the hospital and still perceive that Accreditation has a strong influence on performance. However, they identify that it is necessary to develop projects that add resources from other sources, in addition to the contract and agreement with public bodies, because, in this way, they all would direct or influence public bodies to channel resources from the hospital, based on the statement of the respondents.

Resolution Perception
In this category, we sought to identify the perception of stakeholders regarding the hospital's performance based on resolution in the economic and service order. We also sought to identify whether, being a 100% SUS hospital, the treatment offered would be inferior compared to that practiced in other private or philanthropic hospitals in Caxias do Sul, always considering whether Accreditation would have an influence on performance.
For Campos (1988), thinking about resolution presupposes considering the correlation between services and the objectives for which they were created. When considering the competence limit of each service, other authors define that the resolution of each service lies in the fact that they are well prepared to meet the needs of their population, even if this means referring them to another service for continuity of care (Turrini, Lebrão & Cesar, 2008 And Accreditation has a very big impact on that because it's day-to-day care, with Accreditation it's protocol, standardization..." (SE7) "I see how patients are well cared for, comfortable... Accreditation makes the entire system organized and resources are invested and all of them benefit, I see that they are well cared for not only in the medical sense, but in the physical part also." (SE8) All stakeholders perceive that there is no difference in treatment. On the contrary, external stakeholders understand that the quality developed through Accreditation, associated with the humanized form of care by the hospital team, the treatment is even superior compared to other hospitals, not only in Caxias do Sul, but in the State.
Thus, the analysis of the resolution of services must consider its organization and attribution by levels of care and can be evaluated on two levels: internally, through their ability to meet the demand and refer people who need specialized care and, also, within the health network, from the initial care provision of the user to its resolution in other levels of health care (Turrini et al. 2008  Hospital Accreditation has any influence, some stakeholders consider that the difference is related to structure and hospitality, especially when compared to private hospitals. They identify that humanized care and management stand out strongly, even compared to other hospitals that are also certified with Hospital Accreditation. Stakeholder responses are directly related to the authors Turrini et al. (2008), as it can be evaluated in the aspects of the ability to meet the demand and refer people who need specialized care and, also, within the health network, from the initial care of the user to its resolution in other levels of health care.

Perception of Humanization
In non-financial organizational performance, it is important to consider non-tangible data, which in this context we sought to identify from the stakeholders about the service provided by the care team, that contribute to the successful implementation of Hospital Accreditation, as well as the perception when comparing the hospital with the other SUS services in Brazil.
According to the Ministry of Health, "to humanize is to guarantee the word its ethical dignity". The process of humanization of hospital work implies organizational, institutional, professional, and personal dimensions, and it is up to users of the Unified Health System to question and evaluate the rules that restrict access and participation of families and users. Humanization in the hospital environment must be understood not only

Perception of Stakeholders on organizational performance in a Unified Health System hospital (100% SUS) with Level III Hospital Accreditation, Serra Gaúcha
from the perspective of care and technologies provided by health professionals and services. Strategies such as comprehensive listening, verbal and non-verbal communication, optimization of information between the team and the family, and the patient, adult or child, with the family, should be valued. "Very differentiated quality, not only on my part, but also on the part of patients and users, because we hear a lot that Caxias has the best public health in the state and even outside the state, we hear that people even come from outside..." ( SE7)

It was identified in the responses of the stakeholders that humanization is perceived both in
"there is a very good structure here, I have already heard reports of some patients who end up coming from other states to have the care here... I see that it is much better here." (SE8) Everyone reported that the service provided by the General Hospital is incomparable, especially if it is linked to the images and reports presented on the television news. There are still those who identify that the service

Perception of Stakeholders on organizational performance in a Unified Health System hospital (100% SUS) with Level III Hospital Accreditation, Serra Gaúcha
International Journal for Innovation Education and Research, Vol.10 No.9 (2022), pg. 73 is superior compared to private services, as can be seen in the responses.

General perception of the hospital
In the same way that the General Hospital has a contractual commitment to evaluate the satisfaction of the hospitalized user, the interviewees were asked: What is your first thought when you hear or read the name All interviewees expressed affection, gratitude and recognition that the hospital is a reference in health services, as a model to be followed. These perceptions are subjective, however, it was possible to achieve the objective of the research; To identify the perception of the stakeholders in relation to organizational performance and innovation, after the Hospital Accreditation of the General Hospital of Caxias do Sul -RS.

Final Considerations.
Based on the theoretical foundation, it is identified that organizational performance is configured through indicators which are measurable as financial and non-financial. Hospital Accreditation is a certification granted as a form of recognition of management practices. It is based on the development of methods and monitoring of indicators, in a conscious way and by all parties involved, contributing to a systemic view, generating continuous improvement in processes and service. In addition to focusing on cost reduction, adding humanized care, efficiency, and innovation in services based on medical protocols.
Regarding the qualitative research, it was possible to clearly identify the perception of stakeholders in the a priori categories which are presented in a summarized way. As regards to learning, it was identified that the external stakeholders, despite perceiving the great relevance of the hospital in its general context and excellence in care, comprising resolution and humanization, believe that the Hospital Accreditation of the General

Perception of Stakeholders on organizational performance in a Unified Health System hospital (100% SUS) with Level III Hospital Accreditation, Serra Gaúcha
International Journal for Innovation Education and Research, Vol.10 No.9 (2022), pg. 74 Hospital did not aggregate learning. Considering the perception of stakeholders, they perceive that the credibility and better performance of the General Hospital are linked to other perceptions, in addition to Hospital Accreditation. Crucial factors are the fact that the hospital has a link to the University, the commitment of the professionals who work in the organization and, also, the fact that economic sustainability is affected due to the form of remuneration of the Unified Health System, requiring more effort and strategy from the direction in fundraising.
As for resolution and humanization, all stakeholders perceive that professionals who work in the hospital behave differently from those of other health services. In addition to following the technical protocols, they demonstrate care with the patient in the application of the technique, not only caring about the effectiveness of the drug or treatment. They receive the patients with warmth and treat them with empathy, so that the patient is not only discharged from the hospital recovered, but feeling grateful for the care offered by the professionals.
After the interviews and saturation analysis, it was possible to identify two categories a posteriori that were very evident in the perception of stakeholders. These are a) economic sustainability, and b) a third category of stakeholders, which can be identified as simultaneous action stakeholders, as shown.
Economic sustainability -With regard to financial issues, stakeholders perceive that the form of remuneration practiced by the SUS does not allow for sustainability. Requiring, on the part of the management, efforts in raising funds, from the relationship with politicians in the direction of parliamentary amendments or social projects, with or without a tax waiver. Another strategic action by the management to equalize the financial deficit is the provision of outpatient services such as radiotherapy, diagnostic imaging, and clinical analysis.
However, efforts are insufficient, requiring the participation of society with financial donations through social projects organized by volunteers and companies. All stakeholders claim that they would direct resources or influence public or private agencies because they perceive that the hospital is transparent in the application of the resource. They mention that it is possible to check the targeted resources, found in the works and equipment delivered to society through events, as well as freedom of access for the entire community.
Simultaneous actions Stakeholder -one of the actions foreseen during the identification of stakeholders is their classification between internal (primary) and external (secondary) stakeholders, in order to assist in the categorization and analysis of the power and impact of influence on the project (Rajablu;Marthandan & Yusoff, 2015). According to Cleland, the primary stakeholders are those that make up the project team, with the project manager having some degree of authority and direct influence over them, whereas the secondary stakeholders are those that the project manager does not represent direct authority, exerting influence essentially through their relationship. The authors Rabechini Jr. and Carvalho (2003) present some examples of primary stakeholders such as the project manager, the sponsor, the supplier, the technical staff, the project team, the functional and support manager. For secondary stakeholders, Carvalho and Rabechini Jr. (2011) list the government, class associations, media, the family of those involved, and the user community.
It was identified that the teaching hospital has a third category of stakeholder, which acts simultaneously in the external environment as a client (student) and internal (user service), which are resident doctors and academics who use the General Hospital structure as a learning environment. while serving the public. For this third category, the name of simultaneous action stakeholder is suggested, this category can be attributed to the

Perception of Stakeholders on organizational performance in a Unified Health System hospital (100% SUS) with Level III Hospital Accreditation, Serra Gaúcha
report of SE3 "I speak exempt from my position as an employee and resident here, it is a genuine opinion, I think everyone, [...] the vast majority would be very well treated patients, [...] Personally, I am proud to say that I am a resident at the General Hospital".
Figure 01 identifies that these stakeholders act simultaneously in both categories. In sequence, Table 02 presents a summary of the stakeholders' perception in the a priori categories, learning, credibility, resolution, and humanization.

Figura 1 -Stakeholder categories
Source: Drafted by the author (2020). Accreditation and also because of a link with a university.

RESOLUTION
External Stakeholders understand that the General Hospital has a service equivalent to a private service. Some understand that the service is superior due to the commitment of the professionals who work in the institution.

HUMANIZATION
All stakeholders understand that there is care on the part of the institution's professionals, which aims to serve the patient beyond health condition, demonstrating empathy in the treatment.
In summary, the perception of the client stakeholders regarding the Organizational Performance and Innovation of the General Hospital after the Hospital Accreditation is that the certification promotes the recognition of society as a quality service, which adds learning, credibility and resolution with humanization, being a reference for other hospitals and especially for those that depend on public resources. The research concluded that public hospitals, specifically 100% SUS hospitals and schools, face difficulties in terms of economic

Perception of Stakeholders on organizational performance in a Unified Health System hospital (100% SUS) with Level III Hospital Accreditation, Serra Gaúcha
International Journal for Innovation Education and Research, Vol.10 No.9 (2022), pg. 76 sustainability. However, Hospital Accreditation contributes to better financial performance, producing more care, optimizing public resources, and also providing credibility so that the hospital can raise funds through social projects and the participation of politicians. Hospital Accreditation is not only possible, but essential for a better application of public resources.
The focus of the investigation was limited to the city of Caxias do Sul in a single case study. However, the same survey can be carried out in other hospitals with Hospital Accreditation, as it can provide relevant information. Aspects such as the sustainability context should be included in future research. As a continuation of this study, it is suggested to research forms of funding in addition to the SUS remuneration for the viability of public health services.