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In this article, we sought to identify the source of legitimacy that guided the adoption of Hospital Accreditation in four hospitals in Rio de Janeiro, in addition to assessing whether its adoption was aligned with issues of organizational efficiency. Using Scott's (1995) concepts about types of legitimacy, we conducted a survey consisting of in-depth interviews and semi-structured questionnaires with managers and employees. The result showed normative legitimacy best explained the adoption of hospital accreditation in public and private hospitals in Rio de Janeiro. The search for socially accepted normative values, such as quality of care and patient safety, determined the goals of hospitals that adopted hospital accreditation. The search for efficiency was also proven, evidencing that even in highly institutionalized environments, as in the case of accredited hospitals (Ruef and Scott, 1998), efficiency can go against the search for legitimacy, dismissing hospital certification practices as mere organizational myths. [ABSTRACT FROM AUTHOR]