Gestão hospitalar: gerenciando processos de trabalho em saúde / Hospital management: managing health work processes

A função de gestor hospitalar é invariavelmente complexa, independentemente da região, de fato que, ainda em certos aspectos, os serviços de saúde são mais desafiadores em alguns países, devido à regulação de leitos, financiamento e tecnologias à disposição. Acrescenta-se à extensa relação de demandas gerenciais, a exigência por conhecimentos específicos na gestão dos recursos humanos e físicos. A influência do modelo fragmentado de organização do trabalho, em que cada profissional realiza parcelas do trabalho sem uma integração com as demais áreas envolvidas, tem sido apontada como uma das razões que dificultam a realização de um trabalho em saúde mais integrador e de melhor qualidade, tanto na perspectiva daqueles que o realizam como para aqueles que dele usufruem. A partir do momento em que profissionais de saúde, que trabalham diretamente com o paciente, ocupam coordenações, na medida em que ascendem na organização, passam a desempenhar mais tarefas administrativas. Como exemplo, é possível perceber que uma enfermeira ou médico que coordenam uma unidade de internamento, realizam mais funções administrativas e quase nenhuma técnica, usando seus conhecimentos técnicos para atuar na chefia. Esses profissionais, ao ocupar determinados cargos, nem sempre entendem das atividades administrativas. Com isso, o hospital perde um bom técnico e pode não ganhar um bom chefe. Este trabalho tem uma descrição reflexiva acerca do processo de gestão hospitalar.(AU)

The role of hospital manager is invariably complex, regardless of the region. In some countries, health services are even more challenging due to the regulation of beds, financing, and technologies available. In addition to the extensive list of managerial demands, there is also the requirement for specific knowledge in the management of human and physical resources. The influence of the fragmented model of work organization, where each professional performs portions of the work without integration with the other involved areas, has been pointed out as one of the reasons hindering the accomplishment of a more integrating and better-quality health work, both from the perspective of those who perform it and of those who use it. From the moment health professionals, who work directly with the patient, occupy managerial positions, as they ascend in the organization, they inevitably start to have more administrative tasks. As an example, it is possible to notice that a nurse or doctor who coordinates an inpatient unit performs more administrative functions and almost no technical ones. They use their technical expertise to act in managerial positions. These professionals, when occupying certain positions, are not always fully trained to understand administrative activities. Thus, the hospital ends up losing a good technician worker and may not always get a good manager in return. This work presents a reflexive description on the hospital management process.(AU)

Investigating the challenges and opportunities for medicines management in an NHS field hospital during the COVID-19 pandemic.

INTRODUCTION: Hospital admissions from COVID-19 initially increased rapidly within the UK. National Health Service (NHS) field hospitals are part of a capacity building response built at great scale and speed to respond to the anticipated increased demand the NHS faces during this time. NHS Nightingale Hospital Birmingham (NHB) is modelled to treat mild to moderate (non-critical care) COVID-19 disease, to provide step-down capacity for patients in recovery, or for palliating patients in the dying phase of their disease in the Midlands. Opportunities and challenges presented for optimal medicines management (MM) during the development of the NHB are investigated, and a framework developed to support future NHS field hospitals of this model. METHODS: A team, comprised of an associate medical director, trust chief pharmacist and senior pharmacists iteratively developed a framework to convert the large non-hospital setting into a functioning NHS field hospital with standardised MM processes adjusted appropriately to cope with operational constraints in the pandemic situation. NHB has, because of its repurposing, both challenges and advantages affecting MM that influence development of the framework. Throughout implementation, a 7-week period between announcement and opening, there was continuous evaluation, external stakeholder validation and peer review. RESULTS: The PESTLE model, a mechanism of analysis to identify elements of a project environment (Political, Environmental, Social, Technological, Legal and Economic), was applied to identify influencing factors and support detailed project planning. Compliance with medicines legislation was at the forefront of all MM process development for the NHB field hospital. Internal factors were identified by the core MM team, resulting in a workforce, education & training and clinical pharmacy MM plan. DISCUSSION: MM processes are extensive and integral to NHS field hospitals. The presented framework of influencing factors may support future NHS field hospital development. It is pertinent to have a broad team working approach to any large-scale project such as outlined here, and suggest the identified factors be used as a core framework for development of any future MM processes in NHS field hospitals.

Enfermedad COVID-19: el hospital del futuro ya está aquí / COVID-19 disease: the hospital of the future is already here

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Fundação pública de direito privado / Public foundation of private law

Muitas alternativas de gestão de unidades públicas de saúde têm sido discutidas com o objetivo de aumentar a eficiência destas e garantir melhorias no atendimento e serviços prestados à população em geral. Dentre os diversos modelos de gerência atualmente em voga, como opção à administração direta tem-se: Fundações Públicas de direito público e as de direito privado, Autarquia, Consórcio Público, Empresa Estatal, vínculos paraestatais e de colaboração, Organização Social (OS), Organização da Sociedade Civil de Interesse Público (OSCIP) e Fundação de Apoio.

Many alternatives for the management of public health units have been discussed with the objective of increasing their efficiency and ensuring improvements in care and services provided to the general population. Among the various management models currently in vogue, as an option for direct administration are: Public Foundations of public law and those of private law, Municipality, Public Consortium, State Company, parastate and collaborative links, Social Organization (OS), Civil Society Organization of Public Interest (OSCIP) and Support Foundation.

[Emergency overcrowding and hospital organization: Causes and solutions]. / La saturation de la structure des urgences et le rôle de l'organisation hospitalière : réflexions sur les causes et les solutions.

Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.

Scoping Review of Hospital Business Continuity Plans to Validate the Improvement after the 2011 Great East Japan Earthquake and Tsunami.

During a disaster, all hospitals are expected to function as "social critical institutions" that protect the lives and health of people. In recent disasters, numerous hospitals were damaged, and this hampered the recovery of the affected communities. Had these hospitals business continuity plans (BCPs) to recover quickly after the disaster, most of the damage could have been avoided. This study conducted a scoping review of the historical trend and regional differences in hospital BCPs to validate the improvement of the BCP concept based on our own experience at Tohoku University Hospital, which was affected by the 2011 Great East Japan Earthquake and Tsunami (GEJET). We searched PubMed by using keywords related to BCP and adapted 97 articles for our analysis. The number of articles on hospital BCPs has increased in the 2000s, especially after Hurricane Katrina in 2005. While there are regional specificity of hazards, there were many common topics and visions for BCP implementation, education, and drills. From our 2011 GEJET experience, we found that BCPs assuming region-specific disasters are applicable in various types of disasters. Thus, we suggest the following integral and universal components for hospital BCPs: (1) alternative methods and resources, (2) priority of operation, and (3) resource management. Even if the type and extent of disasters vary, the development of BCPs and business continuity management strategies that utilize the abovementioned integral components can help a hospital survive disasters in the future.

Reconsidering hospital EHR adoption at the dawn of HITECH: implications of the reported 9% adoption of a "basic" EHR.

OBJECTIVE: In 2009, a prominent national report stated that 9% of US hospitals had adopted a "basic" electronic health record (EHR) system. This statistic was widely cited and became a memetic anchor point for EHR adoption at the dawn of HITECH. However, its calculation relies on specific treatment of the data; alternative approaches may have led to a different sense of US hospitals' EHR adoption and different subsequent public policy. MATERIALS AND METHODS: We reanalyzed the 2008 American Heart Association Information Technology supplement and complementary sources to produce a range of estimates of EHR adoption. Estimates included the mean and median number of EHR functionalities adopted, figures derived from an item response theory-based approach, and alternative estimates from the published literature. We then plotted an alternative definition of national progress toward hospital EHR adoption from 2008 to 2018. RESULTS: By 2008, 73% of hospitals had begun the transition to an EHR, and the majority of hospitals had adopted at least 6 of the 10 functionalities of a basic system. In the aggregate, national progress toward basic EHR adoption was 58% complete, and, when accounting for measurement error, we estimate that 30% of hospitals may have adopted a basic EHR. DISCUSSION: The approach used to develop the 9% figure resulted in an estimate at the extreme lower bound of what could be derived from the available data and likely did not reflect hospitals' overall progress in EHR adoption. CONCLUSION: The memetic 9% figure shaped nationwide thinking and policy making about EHR adoption; alternative representations of the data may have led to different policy.

Gestión hospitalaria en la pandemia / Healthcare management during COVID-19 pandemia

OBJETIVOS: Describir la organización de un hospital durante la pandemia por COVID-19, prestando atención a aspectos tanto organizativos como de liderazgo, y considerando todas las áreas hospitalarias, incluido el quirófano. MATERIAL Y MÉTODOS: Revisión de la literatura en relación con los consejos organizativos para la gestión hospitalaria dentro de la pandemia. Además, se han tenido en consideración las recomendaciones de sociedades, de instituciones como la OMS, el CDC, el ECDC, Ministerio de Sanidad y Consejería de Sanidad de Madrid y la propia experiencia del centro. RESULTADOS: Descripción de los elementos claves para la organización, así como de los diferentes ámbitos de actuación dentro de un hospital: urgencias, consultas,hospitalización y quirófanos. CONCLUSIONES: La gestión durante una pandemia requiere un alto grado de agilidad en la respuesta y plasticidad en las personas. Todas las estructuras hospitalarias deben adecuarse a una situación para la que no han sido concebidas y todo el personal debe ponerse al servicio de una enfermedad que condiciona todas las decisiones. Ser capaz de adaptarse y de intentar adelantarse a lo que va a ocurrir son las claves del éxito

OBJECTIVES: To describe the organization of a hospital during the COVID-19 pandemic, paying attention to both organizational and leadership aspects, and considering all hospital areas, including the operating room. MATERIAL AND METHODS: Review of the literature regarding the organizational councils for hospital management within the pandemic. In addition, the recommendations of societies, institutions such as the WHO, the CDC, the ECDC, the National Ministry of Health and the Ministry of Health of Madrid and the center’s own experience have been taken into account. RESULTS: Description of the key elements for the organization, as well as the different areas of action within a hospital: emergencies, consultations, hospitalization and operating rooms. CONCLUSIONS: Management during a pandemic requires a high degree of agility in response and plasticity in people. All hospital structures must adapt to a situation for which they have not been conceived and all staff must place themselves at the service of a disease that conditions all decisions. Being able to adapt and try to anticipate what is going to happen are the keys to success

Hospital adoption of multiple health information exchange approaches and information accessibility.

OBJECTIVE: Hospital engagement in electronic health information exchange (HIE) has increased over recent years. We aimed to 1) determine the change in adoption of 3 types of information exchange: secure messaging, provider portals, and use of an HIE; and 2) to assess if growth in each approach corresponded to increased ability to access and integrate patient information from outside providers. METHODS: Panel analysis of all nonfederal, acute care hospitals in the United States using hospital- and year-fixed effects. The sample consisted of 1917 hospitals that responded to the American Hospital Association Information Technology Supplement every year from 2014 to 2016. RESULTS: Adoption of each approach increased by 9-15 percentage points over the study period. The average number of HIE approaches used by each hospital increased from 1.0 to 1.4. Adoption of each approach was associated with increased likelihood that providers routinely had necessary outside information of 4.2-12.7 percentage points and 4.5-13.3 percentage points increase in information integration. Secure messaging was associated with the largest increase in both. Adoption of 1 approach increased the likelihood of having outside information by 10.3 percentage points, while adopting a second approach further increased the likelihood by 9.5 percentage points. Trends in number of approaches and integration were similar. DISCUSSION/CONCLUSION: No single HIE tool provided high levels of usable, integrated health information. Instead, hospitals benefited from adopting multiple tools. Policy initiatives that reduce the complexity of enabling high value HIE could result in broader adoption of HIE and use of information to inform care.

Delivery Hospital Characteristics and Postpartum Maternal Mortality: A National Case-Control Study in France.

BACKGROUND: The variability in resources for managing critical events among maternity hospitals may impact maternal safety. Our main objective was to assess the risk of postpartum maternal death according to hospitals' organizational characteristics. A secondary objective aimed to assess the specific risk of death due to postpartum hemorrhage (PPH). METHODS: This national population-based case-control study included all 2007-2009 postpartum maternal deaths from the national confidential enquiry (n = 147 cases) and a 2010 national representative sample of parturients (n = 14,639 controls). To adjust for referral bias, cases were classified by time when the condition/complication responsible for the death occurred: postpartum maternal deaths due to conditions present before delivery (n = 66) or during or after delivery (n = 81). Characteristics of delivery hospitals included 24/7 on-site availability of an anesthesiologist and an obstetrician, level of perinatal care, number of deliveries annually, and their teaching and profit status. In teaching and other nonprofit hospitals in France, obstetric care is organized on the principle of collective team-based management, while in for-profit hospitals, this organization is based mostly on that of "one woman-one doctor." Logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for postpartum maternal death. RESULTS: The risk of maternal death from prepartum conditions was lower for women who gave birth in for-profit compared with teaching hospitals (aOR, 0.3; 95% CI, 0.1-0.8; P = .02) and in hospitals with <1500 vs ≥1500 annual deliveries (aOR, 0.4; 95% CI, 0.1-0.9; P = .02). Conversely, the risk of postpartum maternal death from complications occurring during or after delivery was higher for women who delivered in for-profit compared with teaching hospitals (aOR, 2.8; 95% CI, 1.3-6.0; P = .009), as was the risk of death from PPH in for-profit versus nonprofit hospitals (aOR, 2.8; 95% CI, 1.2-6.5; P = .019). CONCLUSIONS: After adjustment for the referral bias related to prepartum morbidity, the risk of postpartum maternal mortality in France differs according to the hospital's organizational characteristics.

Perceptions of future hospital management in Finland.

PURPOSE: The purpose of this paper is to describe how Finnish experts perceive future (year 2030) hospital management and leadership. DESIGN/METHODOLOGY/APPROACH: A total of 33 experts participated in a three-round Argument Delphi process. Opposing views of management and leadership in 2030 were analyzed using inductive content analysis. FINDINGS: The experts' perceptions were divided into two main categories: management and leadership orientation and future organization. Perceptions relating to management and leadership orientation were classified as relating to patient-centred, clinical dominance, professionally divided and management career options. Perceptions relating to future management and leadership organization were classified as representing shared, pair, team and the individual-centered leadership. The results highlighted the most distinctive issues raised by the participants. RESEARCH LIMITATIONS/IMPLICATIONS: This qualitative study was conducted in the context of Finnish healthcare according to the principles of the Argument Delphi Method. The panel consisted of high-level experts representing a diverse set of roles. However, as suggested in previous literature, these experts may not be the most astute in predicting the future development of hospital organizations. PRACTICAL IMPLICATIONS: The findings can be used to develop and renew management and leadership training and management practices in hospitals. SOCIAL IMPLICATIONS: The findings can be exploited in discussions, planning and decision making regarding future management and leadership in hospitals. ORIGINALITY/VALUE: Only a few studies have investigated perceptions of future management in hospitals. This study adopted the Argument Delphi Method to identify distinct perceptions on the future orientation and organization of management and leadership in hospitals.

Did we learn the lesson after 60 years of Management by Objectives? A survey among former physician executives in German hospitals.

BACKGROUND: Management by Objectives (MbO) has been shown to establish efficient team work in both industry and medicine. Its most important prerequisite for success is target agreements between managers and medical professionals on equal footing. In medicine, lump-sum financing urges the delivery of a health care service with minimal effort. Consequently, daily clinical life changed, with economic goals seeming to become priority over medical principles. OBJECTIVE: To determine how well MbO can still be practiced in hospitals with lumped treatment prices. METHODS: We used an anonymized questionnaire for already retired physician executives who completed their active leadership positions between 2010 and 2015 in Saxony (Germany). We asked various type of target agreements that had been used in order to achieve medical or economic targets. RESULTS AND CONCLUSIONS: Out of 111 former executives, the questionnaires of 25 respondents could be analysed. Eight respondents confirmed target agreements that were mostly set by managing directors. If used, most targets had not been adapted to the infrastructure and personnel strength, nor were they coordinated with neighbouring departments. Four respondents received financial incentives. Most medical executives were unsatisfied and preferred to abandon further goal setting. Due to the low number of cases, the representativeness of the study is limited. Nevertheless, it might be questioned if a flat-rate remuneration system facilitates the change into an authoritarian leadership concept.

Positive Predictive Value of Administrative Data for Neonatal Abstinence Syndrome.

OBJECTIVES: Neonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome experienced by some infants with opioid exposure. Hospital administrative data are commonly used for research and surveillance but have not been validated for NAS. Our objectives for this study were to validate the diagnostic codes for NAS and to develop an algorithm to optimize identification. METHODS: Tennessee Medicaid claims from 2009 to 2011 (primary sample) and 2016 (secondary sample; post-International Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM]) were obtained. Cases of NAS were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification code (2009-2011) 779.5 and ICD-10-CM code (2016) P96.1. Medical record review cases were then conducted by 2 physicians using a standardized algorithm, and positive predictive value (PPV) was calculated. Algorithms were developed for optimizing the identification of NAS in administrative data. RESULTS: In our primary sample of 112 029 mother-infant dyads, 950 potential NAS cases were identified from Medicaid claims data and reviewed. Among reviewed records, 863 were confirmed as having NAS (including 628 [66.1%] cases identified as NAS requiring pharmacotherapy, 224 [23.5%] as NAS not requiring pharmacotherapy, and 11 [1.2%] as iatrogenic NAS), and 87 (9.2%) did not meet clinical criteria for NAS. The PPV of the International Classification of Diseases, Ninth Revision, Clinical Modification code for NAS in clinically confirmed NAS was 91% (95% confidence interval: 88.8%-92.5%). Similarly, the PPV for the ICD-10-CM code in the secondary sample was 98.2% (95% confidence interval: 95.4%-99.2%). Algorithms using elements from the Medicaid claims and from length of stay improved PPV. CONCLUSIONS: In a large population-based cohort of Medicaid participants, hospital administrative data had a high PPV in identifying cases of clinically diagnosed NAS.

Effective Governance and Hospital Boards Revisited: Reflections on 25 Years of Research.

This study reviews and synthesizes empirical research literature focusing on the relationship between boards of directors and organizational effectiveness of U.S. hospitals. The study examines literature published in scholarly journals during the period of 1991-2017. Fifty-one empirical articles were identified that met the study's inclusion criteria. A framework from the corporate governance and nonprofit governance literature is used to classify the articles according to level of analysis (individual actors, governing bodies, organizations, and networks, alliances and multiorganizational initiatives) and focus of research (formal structure and behavioral dynamics-including informal structures and processes). Results are discussed, emerging trends are identified, and recommendations are made for future research.

[Increasing Complexity in Performance Delivery - Management Approach for Tertiary Care Centers]. / Komplexitätssteigerung in der Leistungserstellung ­ Managementansätze für ein Zentrumsspital.

Increasing Complexity in Performance Delivery - Management Approach for Tertiary Care Centers Abstract. General social trends such as individualization and female shift increase the complexity for management in both technical and system management in addition to the inherent development in the hospital industry such as subspecialization, ageing societies and multimorbidity. Reduction of complexity is therefore absolutely necessary in order to be able to manage in a patient-friendly way as a maximum care provider. Reducing complexity means resolving therapeutic conflicts. Essential tools for this are digitization, a comprehensive quality paradigm that includes patient experience, patient assessment of treatment outcomes, indication and service quality, and good management. The latter integrates the fragmentation of skills and knowledge of a subspecialized medicine through appropriate system design. This requires the appropriate functional strategies and a comprehensive process management competence that can transform the numerous interfaces into seams.

Relationship between lean practices, soft total quality management and innovation skills in Lebanese hospitals.

BACKGROUND: Lean practices are critical to eliminate waste and enhance the quality of healthcare services through different improvement approaches of total quality management (TQM). In particular, the soft side of TQM is used to develop the innovation skills of employees that are essential for the continuous improvement strategies of hospitals. AIM: The main objective was to study the relationship between lean practices, soft TQM and innovation skills in Lebanese hospitals. METHODS: A quantitative methodology was applied by surveying 352 employees from private and public hospitals in Lebanon. The primary collected data were valid and reliable when analysed by SPSS and AMOS software as a part of structural equation modelling. RESULTS: Lean practices significantly influenced the innovation skills; however, soft TQM did not mediate this relationship because it was not well implemented, especially at the level of people-based management and continuous improvement. CONCLUSION: This study has implications for healthcare practitioners to make greater efforts to implement lean practices and soft TQM. Future studies are suggested to highlight different challenges facing quality improvement in the Region.