Brazil's health system functionality amidst of the COVID-19 pandemic: An analysis of resilience.

Background: As of December 31, 2020, Brazil had the second-highest burden of COVID-19 worldwide. Given the absence of federal government coordination, it was up to the local governments to maintain healthcare provision for non-COVID health issues. In this descriptive study, we aimed to discuss the SUS functionality and resilience, describing the impact of the pandemic on non-COVID health services delivery while considering the regional inequalities of the allocation of financing health system, health infrastructure and health workforce. Methods: We used input-output framework based on the World Health Organization (WHO) Health System Building Blocks to estimate health system functionality and resilience. An ecological assessment was designed to calculated mean relative changes to compare the first year of the pandemic in Brazil with the previous one. All data used in this study were anonymized and made available by the Brazilian Ministry of Health. Input indicators were categorized in health system financing (federal funding received as well as expenditure of both state and city governments), health system's infrastructure (hospital beds) and health workforce (healthcare workers positions). Output indicators were categorized into nine different groups of service delivery procedures. To explore the relationship between the variation in procedures with socioeconomic conditions, we used the Socioeconomic Vulnerability Index (SVI). Findings: State governments had a 38·6% increase in federal transfers, while municipal governments had a 33·9% increase. The increase of ICU beds reached its peak in the third quarter of 2020, averaging 72·1% by the end of the year. The country also saw an increase in jobs for registered nurses (13·6%), nurse assistants (8·5%), physiotherapists (7·9%), and medical doctors (4·9%). All procedures underwent expressive reduction: Screenings (-42·6%); Diagnostic procedures (-28·9%); Physician appointments (-42·5%); Low and medium complexity surgeries (-59·7%); High complexity surgeries (-27·9%); Transplants (-44·7%); Treatments and clinical procedures due to injuries of external causes (-19·1%); Irrepressible procedures (-8·5%); and Childbirths (-12·6%). The most significant drop in procedures happened in the first quarter of the pandemic, followed by progressive increase; most regions had not yet recovered by the end of 2020. State-level changes in numbers of procedures point towards a negative trend with SVI. Interpretation: The Brazilian Government did not consider that socioeconomically vulnerable states were at a higher risk of being impacted by the overburden of the health system caused by the COVID-19, which resulted in poorer health system functionality for those vulnerable states. The lack of proper planning to improve health system resilience resulted in the decrease of a quarter of the amount of healthcare procedures increasing the already existing health disparities in the country. Funding: MCTIC/CNPQ/FNDCT/MS/SCTIE/DECIT No 07/2020.

Atenção primária na saúde suplementar brasileira: estudo qualitativo em planos de saúde / Primary health care in brazilian supplementary health: a qualitative study with selected healthplans

Objetivo -A atenção primária à saúde (APS) tem sido considerada como o pilar da organização do sistema de saúde. Apesar das iniciativas indutoras da Agência Nacional de Saúde Suplementar (ANS), os programas ainda evidenciam baixo alcance,tanto para os beneficiários quanto para a rede assistencial, com impacto limitado nos resultados clínicos, operacionais e financeiros. O presente estudo visa analisar os fatores que podem ser potenciais barreiras para uma maior escala da APS na saúde suplementar brasileira. Métodos -Trata-se de estudo qualitativo envolvendo amostra de gestores de operadoras de saúde selecionadas pelo Laboratório de Inovação de Atenção Primária na Saúde Suplementar. Resultados -No total, 12 profissionais foram entrevistados, de diferentes tipos de operadoras de saúde. A análise qualitativa permitiu o agrupamento em grandes áreas, envolvendo as condições e os desafios de implantação, de ampliação da escala, de integração com os outros níveis de assistência e o engajamento dos usuários. Finalmente, foram identificados caminhos para que a APS tenha mais escala e atinja os resultados desejados. Conclusão -Apesar de se reconhecer a APS como o elemento central na organização do sistema, integrado à rede assistencial, ela ainda não é amplamente adotada na saúde suplementar brasileira. Os gestores dos programas de APS que participaram desta pesquisa destacaram pontos fundamentais a serem abordados, nos diferentes níveis das organizações.

Objective -Primary health care (PHC) has been considered the pillar of the organization of the health system. Despite the ANS-inducing initiatives, they still show low scale, both for beneficiaries and the assistance network, with limited impact on clinical, operational, and financial results. The present study aims to analyze the factors that may be potential barriers to a larger scale of PHC in Brazilian supplementary health. Methods -This is a qualitative study involving a sample of managers of health plans selected by the Innovation Laboratory on Experiences of Primary Care in Brazilian Supplementary Health. Results -In total, 12 professionals were interviewed, from different types of health operators. The qualitative analysis allowed grouping in large areas, involving the conditions and deployment challenges, the scale of expansion, integration with other levels of care and user engagement. Finally, pathways have been identified for the PHC to have more scale and achieve the desired results. Conclusions -Although PHC is recognized as the central element in the organization of the system, integrated into the care network,it is not yet widely adopted in Brazilian supplementary health. The PHC program managers who participated in this research highlighted fundamental points to be addressed, at different levels of organizations.

Principles of clinical management: connecting management, healthcare and education in health. / Princípios para a gestão da clínica: conectando gestão, atenção à saúde e educação na saúde.

This paper aims at proposing validated principles to underpin clinical management as a means to transform healthcare for integrated healthcare systems. The starting point was the conception of clinical management based on structuring elements that do not separate management, care and education. The authors' proposal was submitted to specialists so that a consensus could be reached. At the end of the process, the following principles of clinical management were presented: (1) Focus on health needs and comprehensive care, (2) Quality and safety in healthcare, (3) Articulation and legitimation of different health practices and types of knowledge to face health problems, (4) Power sharing and co-accountability among managers, health professionals and citizens in healthcare production; (5) Education of people and organizations; (6) Focus on outcomes that add value to health and life; (7) Transparency and accountability regarding collective interests. It is concluded that the principles of clinical management express connections that shed new light on management, healthcare, and education in integrated healthcare systems, requiring critical awareness in relation to the simultaneity of "permanence" and change in practices.

O artigo objetiva propor princípios validados que norteariam uma gestão da clínica voltada à transformação da atenção à saúde, para sistemas integrados de saúde. Partiu-se da concepção de gestão da clínica configurada a partir de certos elementos estruturantes que não separam gestão, cuidado e educação. A proposta dos autores passou por processo de estabelecimento de consenso entre especialistas convidados. Como resultados, são apresentados os seguintes princípios da gestão da clínica: (1) Orientação às necessidades de saúde e à integralidade do cuidado; (2) Qualidade e segurança no cuidado em saúde; (3) Articulação e valorização dos diferentes saberes e práticas em saúde para o enfrentamento dos problemas de saúde; (4) Compartilhamento de poder e corresponsabilização entre gestores, profissionais de saúde e cidadãos na produção da atenção em saúde; (5) Educação de pessoas e da organização; (6) Orientação aos resultados que agreguem valor à saúde e à vida e (7) Transparência e responsabilização com os interesses coletivos. Conclui-se que os princípios da gestão da clínica expressam conexões que lançam uma nova luz sobre a gestão, atenção à saúde e educação em sistemas integrados e demandam uma consciência crítica em relação à simultaneidade de permanências e mudanças de práticas.

A Polissemia da Governança Clínica: uma revisão da literatura / The Polisemy of Clinical Governance: a review of literature

Resumo O artigo objetiva explorar a conceituação da gestão da clínica visando à compreensão dos diversos sentidos que poderão ser atribuídos a essa expressão. Essa discussão tanto pode contribuir para o planejamento e a organização dos serviços de saúde voltados para a gestão da clínica, quanto no estabelecimento de princípios para a elaboração de ações nessa área. Metodologicamente, o estudo consiste numa revisão bibliográfica de cunho qualitativo, com descritores da Biblioteca Virtual em Saúde (BVS). Em termos de resultados, destacam-se sete temas que sintetizam a análise das fontes: gestão, promoção da qualidade, monitoramento ou auditoria clínica, educação, responsabilidade, segurança no cuidado e dimensão sistêmica. Conclui-se que a variação de sentidos relaciona-se à forma como os autores dos estudos revisados expressam ou desdobram os componentes conceituais estruturantes amplamente aceitos como governança clínica. Observase que falta um maior foco em discussões sobre o planejamento e as políticas relacionadas à governança clínica.

Abstract The article aims to explore the concept of clinical management, with a view towards understanding the diverse meanings that could be attributed to that expression. This discussion can contribute to the planning and organization of health services geared to the management of clinical practices, as well as to set forth principles to draft actions in that field. Methodologically, the study consists of a qualitative literature review, using keywords of the Virtual Health Library (VHL). In terms of results, seven topics stand out that synthesize the analysis of sources: management, quality promotion, clinical monitoring or auditing, education, responsibility or accountability, safety in care and a systemic dimension. The conclusion is that the variation of meanings relates to the way in which the authors of the studies reviewed express or unfold the structuring conceptual components broadly accepted as clinical governance. What we observe is a lack of a greater focus on discussions regarding planning and policies relating to clinical governance.

The Polisemy of Clinical Governance: a review of literature.

The article aims to explore the concept of clinical management, with a view towards understanding the diverse meanings that could be attributed to that expression. This discussion can contribute to the planning and organization of health services geared to the management of clinical practices, as well as to set forth principles to draft actions in that field. Methodologically, the study consists of a qualitative literature review, using keywords of the Virtual Health Library (VHL). In terms of results, seven topics stand out that synthesize the analysis of sources: management, quality promotion, clinical monitoring or auditing, education, responsibility or accountability, safety in care and a systemic dimension. The conclusion is that the variation of meanings relates to the way in which the authors of the studies reviewed express or unfold the structuring conceptual components broadly accepted as clinical governance. What we observe is a lack of a greater focus on discussions regarding planning and policies relating to clinical governance.

[External evaluation of hospital organizations in Brazil: could things be done differently?]. / Avaliação externa de organizações hospitalares no Brasil: podemos fazer diferente?

This paper addresses different aspects related to the use of external evaluation models of health services in Brazil, especially hospital accreditation. It is based upon the author´s experience in implementing quality evaluation models in hospitals, as well as on her master and PhD works. The author presents a few aspects concerning the impact of the use of these models in hospitals and the specificities of their application. The results are listed: management enhancement, standardization of processes, personnel training, teamwork, patient-focused care, motivation, external recognition, culture change. The author points out the sundry aspects concerning the way such models are used in Brazilian hospitals.

Avaliação externa de organizações hospitalares no Brasil: podemos fazer diferente? / External evaluation of hospital organizations in Brazil: could things be done differently?

Este artigo aborda aspectos relacionados ao uso de modelos de avaliação externa de serviços de saúde no Brasil, sobretudo acreditação hospitalar, a partir da experiência da autora com a implementação de modelos de avaliação da qualidade em hospitais, bem como de sua reflexão sobre acreditação enquanto objeto de estudo da pós-graduação. A autora aponta alguns dos resultados do uso destes modelos em hospitais e as especificidades de sua aplicação. Esses resultados são enumerados: aprimoramento da gestão, padronização de processos, treinamento de pessoal, trabalho em equipe, atenção focada no paciente, motivação, reconhecimento externo, mudança de cultura. A autora problematiza o modo como tais modelos têm sido empregados nos hospitais brasileiros.

This paper addresses different aspects related to the use of external evaluation models of health services in Brazil, especially hospital accreditation. It is based upon the author´s experience in implementing quality evaluation models in hospitals, as well as on her master and PhD works. The author presents a few aspects concerning the impact of the use of these models in hospitals and the specificities of their application. The results are listed: management enhancement, standardization of processes, personnel training, teamwork, patient-focused care, motivation, external recognition, culture change. The author points out the sundry aspects concerning the way such models are used in Brazilian hospitals.

Barriers to participation in a patient satisfaction survey: who are we missing?

BACKGROUND: A common weakness of patient satisfaction surveys is a suboptimal participation rate. Some patients may be unable to participate, because of language barriers, physical limitations, or mental problems. As the role of these barriers is poorly understood, we aimed to identify patient characteristics that are associated with non-participation in a patient satisfaction survey. METHODOLOGY: At the University Hospitals of Geneva, Switzerland, a patient satisfaction survey is regularly conducted among all adult patients hospitalized for >24 hours on a one-month period in the departments of internal medicine, geriatrics, surgery, neurosciences, psychiatry, and gynaecology-obstetrics. In order to assess the factors associated with non-participation to the patient satisfaction survey, a case-control study was conducted among patients selected for the 2005 survey. Cases (non respondents, n = 195) and controls (respondents, n = 205) were randomly selected from the satisfaction survey, and information about potential barriers to participation was abstracted in a blinded fashion from the patients' medical and nursing charts. PRINCIPAL FINDINGS: Non-participation in the satisfaction survey was independently associated with the presence of a language barrier (odds ratio [OR] 4.53, 95% confidence interval [CI95%]: 2.14-9.59), substance abuse (OR 3.75, CI95%: 1.97-7.14), cognitive limitations (OR 3.72, CI95%: 1.64-8.42), a psychiatric diagnosis (OR 1.99, CI95%: 1.23-3.23) and a sight deficiency (OR 2.07, CI95%: 0.98-4.36). The odds ratio for non-participation increased gradually with the number of predictors. CONCLUSIONS: Five barriers to non-participation in a mail survey were identified. Gathering patient feedback through mailed surveys may lead to an under-representation of some patient subgroups.

Does information about risks and benefits improve the decision-making process in cancer screening - randomized study.

BACKGROUND: Whether the provision of evidence-based information improves satisfaction with decision-making is unclear. OBJECTIVE: To examine whether information about risks and benefits of cancer screening leads to a higher satisfaction with the decision that was made. METHODS: Randomized mail survey in the general population, among 2333 adults aged 30-60 years. The survey included a hypothetical cancer screening scenario that included varying amounts of information about benefits and risks of screening (factorial randomized design). The decision process was evaluated by a 6 item scale, with scores between 0 (lowest score) and 100 (highest score). RESULTS: Substantial proportions of respondents "completely agreed" that the decision reflected what was most important to them (61.2%), were satisfied with their decision (56.0%), were certain of their decision (54.1%), thought that the best choice for them was obvious (53.5%) and that the decision was easy to make (44.1%). The Cronbach alpha coefficient of the scale was 0.88, the mean score was 82.5, and the standard deviation 17.5. Providing information about benefits increased the decision evaluation score only modestly (+1.1, p=0.11); in contrast, providing information about risks sharply reduced the score (-5.1, p<0.001). Those who refused the screening test had lower scores than those who accepted the screening test (69.2 versus 85.6, p<0.001). CONCLUSIONS: Contrary to expectations, informing potential participants about the risks of cancer screening lowered their assessment of the decision process.

Impact of information about risks and benefits of cancer screening on intended participation.

BACKGROUND: Providing comprehensive information about the risks and benefits of cancer screening is ethically necessary, but information about risks may decrease participation. This study explored the impact of information on intended participation using a randomised factorial design. METHODS: We conducted a mail survey of 2333 adults living in Geneva, Switzerland. Each participant was given one randomly chosen version of a scenario that described a hypothetical cancer screening test, and was asked whether he or she would accept to undergo screening. The versions varied in terms of the amount of information about risks and benefits. RESULTS: Respondents who received information about risks associated with screening were more likely to refuse participation (odds ratio 2.6 (95% confidence interval (CI) 2.0-3.5)) than those who received minimal information. In contrast, information about benefits had no impact on intended participation (odds ratio 1.0 (95% CI 0.8-1.2)). The impact of information about risks was significantly stronger in women than in men, in respondents who were in poorer health, who have had a doctor visit in the past 6months, those who have had a cancer screening test in the past 3years, and those who reported a high desire for autonomy in medical decisions. CONCLUSIONS: Informing potential participants about the risks of screening may reduce participation rates. Enhanced information about the benefits of screening does not counterbalance this effect.

A first evaluation of an educational program for health care providers in a long-term care facility to prevent foot complications.

Patients with diabetes and chronic neurological disorders are most commonly "at-risk" with foot problems. The identification of that population is therefore mandatory to prevent severe foot lesions. However, not all health care providers (HCPs) are involved in the screening process in institutions. The authors' aim was to develop and evaluate an educational program for HCP in the field of at-risk foot. All HCPs of the Loëx Hospital (Department of Rehabilitation and Geriatrics, University Hospitals of Geneva) participated in a longitudinal prospective study. Different professions of HCP (doctors, nurses, nursing aides, physiotherapists, occupational therapists, speech-language therapists, and psychologists) attended a structured educational program during a 1-year period based on a specific consultation that the authors developed. During the sessions, risk factors and therapeutic and preventive interventions are discussed with both the patient and care givers. A questionnaire was developed and used to evaluate (1) initial knowledge of HCP in the field of at-risk foot and (2) the impact of the program on the knowledge of HCP 12 months after starting the program. Twelve months after initiating the program, a significant knowledge improvement was noted in all groups of HCP except medical doctors. Nurses presented the most significant rise in knowledge score (P < .001). In conclusion, the consultation is an acceptable and effective form of long-term educational program for HCP in a hospital setting with a huge majority of patients suffering from chronic vascular and neurological conditions and loss of protective pain sensation at the lower limb.

Accreditation of health service network: challenges and perspectives.

The article presents the experience of applying a quality assessment manual of standards for the quality of care in two Brazilian municipal districts, Londrina and Marília, and Cali and Barranquilla, in Colombia. The assessment model applied was health care network accreditation and it applied standards related to institutional management, health care delivery, and network financial and legal aspects. The objective of this tool is to offer appropriate methodology to assess the quality of care provided to municipal districts and service networks in general, seeking their improvement. The municipal districts applied the manual in part of their network, and indicated positive aspects and those that needed improvement. The inherent systemic vision of the accreditation methodology was considered appropriate to focus on a network or health system. In view of the implementation of health system reform in both countries that included a decentralization process and the need for municipal districts to assess the quality of service delivery, the accreditation methodology can become a highly useful tool for municipal health system management.

Resultados de iniciativas de qualidade em hospitais brasileiros / Outcomes of Quality Initiatives in Brazilian Hospitals

O trabalho reúne experiências de hospitais brasileiros em gestão da qualidade, inspiradas em diferentes modelos de avaliação externa. Discute qualidade em saúde e a situação hospitalar brasileira, com o intuito de caracterizar o ambiente no qual as iniciativas de qualidade em instituições de saúde são desenvolvidas. As diferentes abordagens de gestão da qualidade são apresentadas, comparadas e discutidas. Os resultados destas são apontados, bem como seu modo de implementação e suas especificidades. A importância da qualidade para o contexto da saúde e as diferentes possibilidades de interação com a gestão organizacional são discutidas.This study presents different Brazilian hospitals experiences in quality in healthcare, all of which based on external evaluation models. It discusses various aspects of quality in healthcare, specially the ones concerning the Brazilian hospital context, aiming at characterizing the ambience surrounding quality initiatives in healthcare organizations. The author also presents, compares and discusses different quality management approaches, pointing out its results, implementation processes and specificities. Finally, the study also intends to discuss the importance of quality in the healthcare context as well as its relationship with organizational management...

Resultados de iniciativas de qualidade em hospitais brasileiros / Outcomes of Quality Initiatives in Brazilian Hospitals

O trabalho reúne experiências de hospitais brasileiros em gestão da qualidade, inspiradas em diferentes modelos de avaliação externa. Discute qualidade em saúde e a situação hospitalar brasileira, com o intuito de caracterizar o ambiente no qual as iniciativas de qualidade em instituições de saúde são desenvolvidas. As diferentes abordagens de gestão da qualidade são apresentadas, comparadas e discutidas. Os resultados destas são apontados, bem como seu modo de implementação e suas especificidades. A importância da qualidade para o contexto da saúde e as diferentes possibilidades de interação com a gestão organizacional são discutidas.This study presents different Brazilian hospitals experiences in quality in healthcare, all of which based on external evaluation models. It discusses various aspects of quality in healthcare, specially the ones concerning the Brazilian hospital context, aiming at characterizing the ambience surrounding quality initiatives in healthcare organizations. The author also presents, compares and discusses different quality management approaches, pointing out its results, implementation processes and specificities. Finally, the study also intends to discuss the importance of quality in the healthcare context as well as its relationship with organizational management...