Experiência de gestão no CREAS em interlocução com a análise institucional / Management experience in CREAS in dialogue with institutional analysis / Experiencia de gestión en CREAS en diálogo con el análisis institucional

Resumo Este texto tem como objetivo refletir acerca da experiência em um cargo de gestão do Centro de Referência Especializado de Assistência Social (CREAS) de uma cidade de grande porte de Minas Gerais, por meio do exame de suas possibilidades instituintes. A reflexão sobre a experiência parte de um processo de supervisão seguido de intervenções realizadas com os(as) técnicos(as) do serviço, com base nas trocas oriundas das reflexões entre teoria e prática. A partir das ideias de René Lourau sobre a Análise Institucional, examinamos a dinâmica institucional presente em cada situação problema e o jogo de forças opostas que se enunciam em contradições nas práticas cotidianas. Além disso, utilizamos concepções de Deleuze e Guattari para pensar os modelos presentes e as linhas de invenção que surgiram entre os profissionais. No percurso, destacamos a separação dos(as) técnicos(as) por núcleo, o que perpassa o trabalho de gestão e a própria atuação no CREAS, atuação que é aqui tratada como um analisador. As conclusões apontam para a importância de empreender leituras institucionais na atuação das equipes na Política de Assistência Social em direção a ações coletivas, pois a atuação do psicólogo ainda apresenta uma série de desafios nesse contexto.(AU)

Abstract This article discusses the management experience in a Specialized Referral Center for Social Assistance (CREAS) from a large city of Minas Gerais, examining its instituting possibilities. To this end, we supervised and performed interventions with the service technicians considering the exchanges between theory and practice. The institutional dynamics in each problem-situation and the opposing forces in contradictions seen in everyday practices were examined in the light of the Institutional Analysis, as discussed by René Lourau. Moreover, the present models and invention lines emerging among professionals were thought through the ideas of Deleuze and Guattari. We verified the division of technicians into nuclei, which crosses the management work and their performance in CREAS, being thus consider as an analyzer. The results indicate the importance of Social Assistance Policy towards collective actions in sustaining institutional readings in team performance, as the psychologist's performance still meets a series of challenges in this context.(AU)

Resumen Este texto pretende reflexionar sobre la experiencia en una posición gerencial del Centro de Referencia Especializado en Asistencia Social (CREAS) en una gran ciudad de Minas Gerais (Brasil), examinando sus posibilidades instituyentes. La reflexión sobre la experiencia se inicia con un proceso de supervisión y presenta intervenciones realizadas con los/as técnicos/as del servicio a partir de los intercambios que surgen de estas reflexiones entre la teoría y la práctica. A partir de las ideas de René Lourau sobre el Análisis Institucional, se analizan las dinámicas institucionales presentes en cada situación problemática y el conjunto de fuerzas opuestas que se enuncian en contradicciones en las prácticas cotidianas. Además, se utiliza el pensamiento de Deleuze y Guattari para pensar los modelos actuales y las líneas de invención que surgieron entre los profesionales. En el camino, se destaca la separación de los/as técnicos/as por núcleos que recorre el trabajo de gestión y el propio desempeño de CREAS, tratándolo como un analizador. Se concluye que es importante mantener las lecturas institucionales en el desempeño de los equipos de la Política de Asistencia Social hacia las acciones colectivas, ya que el desempeño del psicólogo todavía presenta una serie de desafíos en este contexto.(AU)

Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa-a scoping review.

BACKGROUND: Sub-Saharan Africa (SSA) faces the highest burden of disease amenable to surgery while having the lowest surgeon to population ratio in the world. Some 25 SSA countries use surgical task-shifting from physicians to non-physician clinicians (NPCs) as a strategy to increase access to surgery. While many studies have investigated barriers to access to surgical services, there is a dearth of studies that examine the barriers to shifting of surgical tasks to, and the delivery of safe essential surgical care by NPCs, especially in rural areas of SSA. This study aims to identify those barriers and how they vary between surgical disciplines as well as between countries. METHODS: We performed a scoping review of articles published between 2000 and 2018, listed in PubMed or Embase. Full-text articles were read by two reviewers to identify barriers to surgical task-shifting. Cited barriers were counted and categorized, partly based on the World Health Organization (WHO) health systems building blocks. RESULTS: Sixty-two articles met the inclusion criteria, and 14 clusters of barriers were identified, which were assigned to four main categories: primary outcomes, NPC workforce, regulation, and environment and resources. Malawi, Tanzania, Uganda, and Mozambique had the largest number of articles reporting barriers, with Uganda reporting the largest variety of barriers from empirical studies only. Obstetric and gynaecologic surgery had more articles and cited barriers than other specialties. CONCLUSION: A multitude of factors hampers the provision of surgery by NPCs across SSA. The two main issues are surgical pre-requisites and the need for regulatory and professional frameworks to legitimate and control the surgical practice of NPCs.

Setting priorities for rural allied health in Australia: a scoping review.

INTRODUCTION: The allied health workforce is one of the largest workforces in the health industry. It has a critical role in cost-effective, preventative health care, but it is poorly accessible in rural areas worldwide. This review aimed to inform policy and research priorities for increasing access to rural allied health services in Australia by describing the extent, range and nature of evidence about this workforce. METHODS: A scoping review of published, peer-reviewed rural allied health literature from Australia, Canada, the USA, New Zealand and Japan was obtained from six databases (February 1999 - February 2019). RESULTS: Of 7305 no-duplicate articles, 120 published studies were included: 19 literature reviews, and 101 empirical studies from Australia (n=90), Canada (n=8), USA (n=2) and New Zealand (n=1). Main themes were workforce and scope (n=9), rural pathways (n=44), recruitment and retention (n=31), and models of service (n=36). Of the empirical studies, 83% per cent were cross-sectional; 64% involved surveys; only 7% were at a national scale. Rural providers were shown to have a breadth of practice, servicing large catchments with high patient loads, requiring rural-specific skills. Most rural practitioners had rural backgrounds, but rural youth faced barriers to accessing allied health courses. Rural training opportunities have increased in Australia but predominantly as short-term placements. Rural placements were associated with increased likelihood of rural work by graduates compared with discipline averages, and high quality placement experiences were linked with return. Recruitment and retention factors may vary by discipline, sector and life stage but important factors were satisfying jobs, workplace supervision, higher employment grade, sustainable workload, professional development and rural career options. Patient-centred planning and regional coordination of public and private providers with clear eligibility and referral to pathways facilitated patient care. Outreach and telehealth models may improve service distribution although require strong local coordination and training for distal staff. CONCLUSION: Evidence suggests that more accessible rural allied health services in Australia should address three key policy areas. First, improving rural jobs with access to senior workplace supervision and career options will help to improve networks of critical mass. Second, training skilled and qualified workers through more continuous, high quality rural pathways is needed to deliver a complementary workforce for the community. Third, distribution depends on networked service models at the regional level, with viable remuneration, outreach and telehealth for practice in smaller communities. More national-scale, longitudinal, outcomes-focused studies are needed using controlled designs.

A comparative analysis on human resources among the specialized ophthalmic medical institutions in China.

BACKGROUND: This study compares perspectives on specialized ophthalmic medical institutions, identifies the gaps in property and geographic offerings, and explores the ways that ophthalmic medical institutions can better allocate resources. The results of this research will increase patient's access to equitable and high-quality ophthalmic care in China. METHODS: The data for this research was gathered from the Survey of China National Eye Care Capacity and Resource for the year 2015. The paper specified the number, professional level of expertise, and educational background of ophthalmic health personnel. The authors of the paper analyzed and compared the differences in ophthalmic care in public vs. private and urban vs. rural regions in China. Descriptive statistics were used. RESULTS: Of the 395 specialized ophthalmic hospitals surveyed, 332 were private medical institutions (84%), and 63 were public (16%). Of the 26 607 ophthalmic personnel surveyed, working in specialized ophthalmic hospitals, 17 561 were in private hospitals (66%) and 9 046 were in public ones (34%). Furthermore, 22 578 of those personnel worked in urban ophthalmic institutions (85%) and 4 029 worked in rural ones (15%). As for regional differences, 14 090 personnel were located in eastern China (53%), 8 828 in central regions (33%), and 3 689 in the western regions (14%). CONCLUSIONS: Public ophthalmic medical institutions still face challenges in providing equitable and widespread care. The availability of well-staffed health centers varies significantly by region. These variations impact resource allocation and directly lead to inequalities and inaccessibility of health services in certain regions of China.

Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters.

BACKGROUND: Traditional bonesetters (TBS) provide the majority of primary fracture care in Nigeria and other low- and middle-income countries (LMICs). They are widely patronized and their services are commonly associated with complications. The aim of the study was to establish the feasibility of formal training of TBS and subsequent integration into the healthcare system. METHODS: Two focus group discussions were conducted involving five TBS and eight orthopaedic surgeons in Enugu Nigeria. Audio-recordings made during the focus groups were transcribed verbatim and analysed using a thematic analysis method. RESULTS: Four themes were identified: Training of TBS, their experiences and challenges; perception of traditional bonesetting by orthopaedic surgeons; need for formal training TBS and willingness to offer and accept formal training to improve TBS practice. Participants (TBS group) acquired their skills through informal training by apprenticeship from relatives and family members. They recognized the need to formalize their training and were willing to accept training support from orthopaedists. The orthopaedists recognized that the TBS play a vital role in filling the gap created by shortage of orthopaedic surgeons and are willing to provide training support to them. CONCLUSION: This study demonstrates the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and outcomes of TBS treatment. This is critical for integration of TBS into the primary healthcare system as orthopaedic technicians. Undoubtedly, this will transform the trauma system in Nigeria and other LMICs where TBS are widely patronized.

Working around hierarchy: Resident and medical assistant teaming.

BACKGROUND: In health care, hierarchy can facilitate getting work done efficiently. It can also hinder performance by suppressing valuable contributions from lower-positioned individuals. Team-based care could mitigate negative effects by creating space for all team members to contribute their unique expertise. PURPOSE: This article sought to understand how resident-medical assistant (MA) dyads interacted before and after primary care clinics transitioned to team-based care. We also studied how they negotiated changes in interpersonal dynamics given the challenge these changes presented to hierarchical norms. METHODOLOGY: We conducted two qualitative interview studies, with 37 residents and 30 MAs at primary care clinics transitioning to team-based care. Interviews were transcribed, coded, and analyzed together using a thematic networks approach and focused coding. RESULTS: An intervention that promoted teamwork prompted resident-MA dyads to change their interactions to counter traditional hierarchy. Residents increasingly asked MAs questions about patient care, and MAs initiated interactions and volunteered ideas more frequently. We also found that MAs and residents expressed some discomfort with the hierarchical ambiguity that their new interactions produced and used alternate scripts to buffer this discomfort and to collaborate as teammates despite formal hierarchy. CONCLUSION: Among resident-MA dyads, a team-based care intervention changed interpersonal dynamics by blurring hierarchical lines and shifting traditional boundaries in ways that were uncomfortable for both groups. They were able to work around discomfort by using new scripts that downplayed the threat to hierarchy. PRACTICE IMPLICATIONS: Organizational structures that encourage greater interprofessional collaboration may neutralize barriers that formal hierarchy in medicine can pose for effective teamwork, but this process can also bring social discomfort. Our findings suggest that health care professionals may use microlevel strategies, such as alternative scripts, to overcome formal hierarchies without openly engaging them. Together, new organizational structures and interaction techniques can help professionals work around hierarchy and improve team performance.

Skill mix: The potential for personal assistants to undertake health-related tasks for people with personal health budgets.

Personal health budgets (PHBs) are being promoted in England as expanding the benefits of choice and control to individuals with healthcare needs. National Health Service (NHS) money is provided to eligible people to use as set out in approved care plans, including direct employment of personal assistants (PAs). The government plans to increase NHS-funded PHBs and to further introduce integrated personal budgets (IPBs). This potentially creates more demand for directly employed or self-employed PAs with health-related skills. The objective of this paper is to report findings from interviews with PAs (n = 105) and key informants (n = 26) from across England, undertaken between October 2016 and August 2017, about the potential for the PA workforce to undertake 'health-related' tasks as facilitated by the introduction of PHBs. PAs were purposefully recruited to ensure the sample included participants from different geographical locations. Key informants were purposefully selected based on their knowledge of policy and community services. Data were analysed quantitatively and qualitatively. This paper focuses on reporting qualitative findings, which are set within the theoretical framework of normalisation process theory to explore implementation challenges of PHBs. The majority (64%) of PAs confirmed that they saw their current roles as congruent with PHBs, were willing to engage with PHBs and undertake health-related tasks. However, 74% of PAs said they would need additional training if enacting such roles. Key informant interviews appraised the development of PHBs as complex, noting incongruences arising from NHS and social care-funded PAs carrying out similar roles within different organisational systems. We conclude the current PA workforce is willing to take on PHB work and is likely to interweave this with work funded by PBs and self-funding care users. Implications include the need for careful consideration of training requirements and delivery for PHB-funded PAs.

Clinical Supervision for Allied Health Professionals Working in Community Health Care Settings: Barriers to Participation.

ISSUE: This study aimed to understand the barriers to clinical supervision participation for allied health professionals working in community health care settings. METHOD: The study used a quantitative descriptive survey to identify barriers to clinical supervision participation and a qualitative analysis of three focus groups. A total of 153 surveys were completed (70% response rate) and 23 clinicians participated in focus groups with themes identified via thematic analysis. OUTCOMES: Allied health professionals valued the need to receive clinical supervision, but a lack of time, variable understanding of clinical supervision, limited access to supervisors, efficacy of clinical supervision, and policy implementation were identified as barriers. CONCLUSION: A multi-pronged organisational approach addressing these key barriers may increase clinical supervision participation in community health care settings.

Guía de acciones intramuros / Intramural Actions Guide

Las acciones intramuros son un conjunto de procedimientos dirigidos a la comunidad y que comprenden intervenciones de promoción, prevención, diagnóstico, tratamiento, rehabilitación y cuidados paliativos que se administran al interior de los establecimientos de salud, de acuerdo al grado de complejidad de la intervención, incorporando en cualquiera de los casos servicios complementarios para la atención de las personas. Incluye atenciones de emergencia, ambulatoria, internamiento y cirugía, de acuerdo a la categoría del establecimiento. Se considera un documento técnico operativo, en la cual se describen actividades, procedimientos y pasos que debe realizar el personal de salud y que corresponden a las acciones integradas enfocadas al cuidado del individuo. En el marco del Modelo de Atención y Gestión se desarrollan acciones en los ámbitos individual, familiar y comunitario y dentro de los servicios ofertados mediante la atención intramuros, el proveedor debe garantizar finalmente la satisfacción del usuario brindando una atención integral e integrada, promoviendo una atención de calidad. Incluye listados con los distintos servicios acorde al tipo de instalación y clasificados por determinados pacientes: embarazo, recién nacido, lactante, preescolar, niño, adolescente, adulto joven, medio y mayor, con sus correspondientes perfiles de atención.

Estrategia nacional de redes integradas de servicios de salud de Guatemala, ENRISSG / National strategy of integrated health services networks of Guatemala, ENRISSG

(Acuerdo ministerial No. 246-2019) Este documento propone un marco conceptual y operativo para entender las RISS desde la perspectiva y realidad de Guatemala, brinda los lineamientos orientadores y las acciones estratégicas para que los actores y prestadores de salud de un distrito o departamento se articulen en redes, optimicen las capacidades instaladas, garanticen la continuidad de la atención y consoliden vínculos interinstitucionales e intersectoriales que permitan abordajes integrales para mejorar la calidad de vida de las personas, las familias y las comunidades. La Estrategia de RISS se promueve como uno de los mecanismos para reducir la fragmentación de los sistemas de salud y como una de las principales expresiones operativas del enfoque de la APS en el proceso de atención integral, integrada y continua a las personas; contribuyendo a hacer una realidad varios de sus elementos más esenciales, tales como la cobertura y el acceso universal; la atención integral, integrada y continua; el cuidado apropiado, y la organización y gestión de los servicios de salud. El objetivo general del acuerdo ministerial que la avala es lograr acceso y cobertura de la salud, a través de la implementación de la Estrategia de Redes integradas, basada en la atención primaria de la salud, que permita una atención de salud equitativa, integral, integrada, continua y de calidad con en el derecho de la salud. Es de aplicación obligatoria para todas las dependencias que organicen e implementen redes integradas de servicios de salud a nivel de la república y permitirá orientar a los gerentes y los equipos multidisciplinarios, interinstitucionales e intersectoriales de un territorio definido, con lineamientos y acciones para el reordenamiento, articulación, coordinación, fortalecimiento y funcionamiento de los servicios de salud en red, fomentando la planificación, implementación, monitoreo, evaluación y rendición de cuentas.