Objective:

To select, pilot test and implement a set of indicators for tertiary public hospitals.

Materials and methods:

Quali-quantitative study in four stages: identification of indicators used internationally; selection and prioritization by utility, feasibility and reliability; exploration of the quality of sources of information in six hospitals; pilot feasibility and reliability, and follow-up measurement.

Results:

From 143 indicators, 64 were selected and eight were prioritized. The scan revealed sources of information deficient. In the pilot, three indicators were feasible with reliability limited. Has conducted workshops to improve records and sources of information; nine hospitals reported measurements of a quarter.

Conclusions:

Eight priority indicators could not be measured immediately due to limitations in the data sources for its construction. It is necessary to improve mechanisms of registration and processing of data in this group of hospital.