Developing sustainable public health care systems for responding to COVID-19 in Japan.

OBJECTIVE: Despite having prevented public health center (PHC) dysfunction in response to COVID-19 during the first wave, public health nurses (PHNs) who play a central role in preventing COVID-19 and supporting community people were unable to share practical knowledge with other PHNs immediately. This report aims to introduce the development of novel sustainable public health care systems with regard to COVID-19 in Japan: task sharing, securing staff, and task shifting. METHODS: A descriptive study. The Japan Ministry of Health, Labour, and Welfare enlisted good practices regarding resource allocation and developing full readiness for sustainable public health care systems in September 2020. RESULTS: Public health center developed systems for office support, infection control, hospital coordination, and outsourced inventory control. To reduce the workload of PHNs, a support team of three to four office workers developed a response manual for residents and a format for telephone consultations regarding COVID-19. Developing an infection control team and web-based system for hospital coordination decreased the workload of PHCs in each community to prepare for the pandemic. CONCLUSION: Public health center should consider managing limited human resources and focus on providing specialized care for COVID-19 patients. Task sharing, securing staff, and task shifting are crucial strategies for developing sustainable public health care systems.

ÖGRO survey on radiotherapy capacity in Austria : Status quo and estimation of future demands.

BACKGROUND: A comprehensive evaluation of the current national and regional radiotherapy capacity in Austria with an estimation of demands for 2020 and 2030 was performed by the Austrian Society for Radiation Oncology, Radiobiology and Medical Radiophysics (ÖGRO). MATERIALS AND METHODS: All Austrian centers provided data on the number of megavoltage (MV) units, treatment series, fractions, percentage of retreatments and complex treatment techniques as well as the daily operating hours for the year 2014. In addition, waiting times until the beginning of radiotherapy were prospectively recorded over the first quarter of 2015. National and international epidemiological prediction data were used to estimate future demands. RESULTS: For a population of 8.51 million, 43 MV units were at disposal. In 14 radiooncological centers, a total of 19,940 series with a mean number of 464 patients per MV unit/year and a mean fraction number of 20 (range 16-24) per case were recorded. The average re-irradiation ratio was 14%. The survey on waiting times until start of treatment showed provision shortages in 40% of centers with a mean waiting time of 13.6 days (range 0.5-29.3 days) and a mean maximum waiting time of 98.2 days. Of all centers, 21% had no or only a limited ability to deliver complex treatment techniques. Predictions for 2020 and 2030 indicate an increased need in the overall number of MV units to a total of 63 and 71, respectively. CONCLUSION: This ÖGRO survey revealed major regional differences in radiooncological capacity. Considering epidemiological developments, an aggravation of the situation can be expected shortly. This analysis serves as a basis for improved public regional health care planning.

Value-Based Reimbursement in Collectively Financed Healthcare Requires Monitoring of Socioeconomic Patient Data to Maintain Equality in Service Provision.

Value-based purchasing is increasingly discussed in association with efforts to develop modern healthcare systems. These models are the most recent example of models derived from health economics research intended to reform collectively financed healthcare. Previous examples have ranged from creation of pseudo-markets to opening these markets for competition between publicly and privately owned enterprises. Most value-based purchasing models tend to ignore that health service provision in collectively financed settings is based on an insurance with political, social obligations attached that challenge the notion of free market and individualist premises which these models rest on. Central social issues related to healthcare in any modern complex society, such as inequality in service provision, can all too easily "disappear" in value-based reform efforts. Based on an analysis of Swedish policy development, we contend that management information systems need to be extended to allow routine monitoring of socioeconomic data when models such as value-based purchasing are introduced in collectively financed health services. The experiences from Sweden are important for health policy in Europe and other regions with collectively financed healthcare plans.

Intensive care unit without walls: seeking patient safety by improving the efficiency of the system.

The term "ICU without walls" refers to innovative management in Intensive Care, based on two key elements: (1) collaboration of all medical and nursing staff involved in patient care during hospitalization and (2) technological support for severity early detection protocols by identifying patients at risk of deterioration throughout the hospital, based on the assessment of vital signs and/or laboratory test values, with the clear aim of improving critical patient safety in the hospitalization process. At present, it can be affirmed that there is important work to be done in the detection of severity and early intervention in patients at risk of organ dysfunction. Such work must be adapted to the circumstances of each center and should include training in the detection of severity, multidisciplinary work in the complete patient clinical process, and the use of technological systems allowing intervention on the basis of monitored laboratory and physiological parameters, with effective and efficient use of the information generated. Not only must information be generated, but also efficient management of such information must also be achieved. It is necessary to improve our activity through innovation in management procedures that facilitate the work of the intensivist, in collaboration with other specialists, throughout the hospital environment. Innovation is furthermore required in the efficient management of the information generated in hospitals, through intelligent and directed usage of the new available technology.

Dental school department strategic planning: A department driven approach.

Drafting strategic plans for dental school departments traditionally involves a committee-led or leadership-driven process, often overlooking input from the majority of departmental members. In this manuscript, the authors advocate for a novel approach wherein departmental activities undergo comprehensive review and analysis, and the establishment of novel objectives through diverse forums of engagement with both faculty and staff, conducted collectively and individually over a concise time limit. This methodology endeavors to solicit input from all departmental constituents through varied channels, fostering an environment wherein all members feel empowered to express their viewpoints, resulting in a strategic plan that resonates with the entire department and enhances the likelihood of successful implementation.

Leadership styles and transformational leadership skills among nurse leaders in Qatar, a cross-sectional study.

AIM: There is a continuing need to implement strategies that create opportunities to develop leadership in Qatar, and to build institutions that can produce effective health managers and leaders. The scarcity of information and studies relating to leadership in this major healthcare corporation must be addressed. This article aims to explore nursing leadership styles and transformational leadership skills among nursing leaders, in Qatar. The study was conducted from October 2020 to January 2021. DESIGN: A cross-sectional Study. METHODS: A validated survey was administered to explore the prevalence of leadership styles and transformational leadership skills. Subsequent statistical data analysis achieved the research objectives. The Multi-Factor Leadership Questionnaire (Western Journal of Nursing Research, 1996) was used as an online de-identified validated questionnaire. RESULTS: Eighty-nine nurses completed the survey. The nurse leaders in this study exhibited leadership traits or qualities that confirm transformational leadership. Some nurse leaders also exhibited transactional and autocratic leadership styles. Directors of nursing exhibit higher levels of transformational leadership style than head nurses, while the latter is more likely to manifest an autocratic leadership style. This study indicates that a development roadmap is needed to transform more nursing leaders into transformational leaders, particularly head nurses, and to universally improve transformational leadership skills among all nursing staff members.

A collaborative clinical placement model for physiotherapy students results in equivalent (or greater) direct patient care activity than that delivered by physiotherapists alone: an observational study.

BACKGROUND: The demand for physiotherapy clinical placements is rising which requires innovative approaches and an understanding of clinical placement models. OBJECTIVE: To determine physiotherapy student contribution to direct patient care activity during a collaborative clinical placement model. Secondary aims determined the impact of clinical area and clinical educator to student (CE:student) ratio and if a group of students could reach equivalent direct patient care activity of a junior or senior physiotherapist. METHOD: Physiotherapy student, and junior and senior physiotherapist occasions of service (OOS) were collected from five Queensland Public Health Sector hospital information management systems from four physiotherapy clinical areas (i.e. cardiorespiratory, musculoskeletal, neurorehabilitation, and orthopedics). Number of days of clinical activity was recorded to provide average OOS/day. RESULTS: Across a 5-week clinical placement a group of physiotherapy students in a collaborative clinical placement model provided on average 10.6 OOS/day (95%CI 10.1-11.2). In three (75%) clinical areas, a group of students participating in higher CE:student ratios produced more OOS/day. Clinical area and CE:student ratio predicted 39% of the variance in student average OOS/day. On average a group of students reached the equivalent direct patient care activity of a junior and senior physiotherapist by week two of a 5-week clinical placement. CONCLUSION: Physiotherapy students in a collaborative clinical placement model met or exceeded the direct patient care activity of a physiotherapist, irrespective of clinical area and CE:student ratio.

Association of Operative Day of the Week with the Length of Stay and Total Hospitalization Costs in Patients with Partial Mastectomy: A Nationwide Database Study in Japan.

Introduction: Length of stay (LOS) is a major concern while optimizing medical resources and costs. Hence, factors influencing LOS should be investigated. In Japan, breast cancer surgery generally involves several days of hospitalization for observation, despite few complications. We hypothesized that the day of surgery (weekday; Monday-Friday) affects LOS. Methods: Using a Japanese nationwide database, we retrospectively identified 146,610 patients who underwent partial mastectomy for stage 0-III breast cancer from July 2010 to March 2017. We conducted multivariable linear and logistic regression analyses adjusting for background characteristics (such as comorbidities and hospital characteristics) with a generalized estimating equation for within-hospital clustering to compare postoperative and total LOS, total hospitalization costs, and postoperative complications between the groups for whom the surgery was performed on different days of the week. Results: In total, whereas the median postoperative LOS was 4 days (interquartile range, 3-6 days), the median total LOS was 6 days (5-8 days). The median total hospitalization cost was 6,189 US dollars (5,609-6,668 US dollars), and postoperative complications occurred in 3.3% of cases. Despite no significant difference in postoperative complications, Monday-Wednesday surgeries showed significantly shorter postoperative LOS than Friday surgeries (-0.11 days [95% confidence interval, -0.14 to -0.07] on Monday with reference to Friday). Nevertheless, Monday surgeries showed significantly increased total LOS (0.69 days [0.64-0.74]) and hospitalization costs (93 US dollars [71-116]) in comparison with Friday surgeries. Conclusions: The operative day of the week was associated with increased LOS and cost, with no difference in postoperative complications after partial mastectomy. Surgeries on Monday involved longer preoperative hospital stays and higher total hospitalization costs than those on other weekdays.

Pay-for-performance and dental procedures: A longitudinal analysis of the Brazilian Program for the Improvement of Access and Quality of Dental Specialities Centres.

OBJECTIVE: Evaluate the impact of a pay-for-performance program on changes in the number of dental procedures performed by public secondary dental care services in Brazil. METHODS: A longitudinal study was carried out with 932 public Dental Specialities Centres (Centro de Especialidades Odontológicas - CEO) that participated in the pay-for-performance Program for the Improvement of Access and Quality of Dental Specialities Centres Services (PMAQ/CEO) and 379 non-CEO centres with secondary dental production. The non-CEO and a group of CEOs did not receive financial incentives from the PMAQ-CEO and served as control groups. Three CEOs groups received additional financial incentives of 20%, 60% or 100% over maintenance values, based on their performance scores. The outcome was the increase (yes/no) in the number of dental procedures between 2011/2013 and 2015/2017. Analyses were carried out using logistic regressions. RESULTS: The number of specialized procedures increased in 48.4% of the services, 44.6% among non-CEO, 52.3% among CEO with no financial incentive and 59.1% among CEO with 100% incentive. The fully adjusted model showed that CEOs receiving 100% of the financial incentive had greater odds of increasing the production of dental procedures (OR = 1.65, 95%CI: 1.09-2.51). Services that increased the number of specialist dentists had (OR = 2.35, 95%CI 1.88-2.94). Municipalities that increased in coverage of private dental insurance had OR = 0.98 (95%CI: 0.94-1.02), and those with higher coverage of primary dental care had OR = 1.02 (95%CI: 0.99-1.05). CONCLUSION: Pay-for-performance may increase the production of dental procedures by CEOs, and mechanisms explaining it must be further investigated.

Assessment of rehabilitation needs in patients after COVID-19: Development of the COVID-19-rehabilitation needs survey.

OBJECTIVE: COVID-19 can result in a broad spectrum of dysfunctions, some of which may persist for long periods, requiring long-term rehabilitation. A comprehensive screening tool is therefore necessary to identify these needs. To date, no data exist on satisfaction with medical and therapeutic interventions for COVID-19 in terms of quality and quantity. The aim of this study is to develop a survey for use with COVID-19 patients during and after the end of the acute phase of the disease. METHODS: Following the definition of dimensions by a group of experts, and a literature search, proven survey instruments were searched for suitable items. In addition, specific questions were developed based on symptoms, and answer options were created with regard to to the complexity of the questions. RESULTS: The COVID-19 Rehabilitation Needs Survey (C19-RehabNeS) consists of the established 36-item Short Form Survey (SF-36) together with the newly developed COVID-19-Rehabilitation Needs Questionnaire (C19-RehabNeQ) (11 further dimensions, respectively 57 items). CONCLUSION: C19-RehabNeS is a comprehensive survey to assess functional limitations and rehabilitation needs during and after infection with SARS-CoV-2 (COVID-19). The strength of this survey is that it combines the assessment of important rehabilitation needs with assessment of satisfaction with the health services, treatment and therapy during the pandemic (C19-RehabNeQ) and assessment of patients' quality of life (SF-36). The C19-RehabNeS survey also enables collection of systematic information on patients with Post-COVID-19 syndrome (Long-COVID-19).

Promoting resilience for children of parents with opioid use disorder: A pilot study of a directed intervention.

PROBLEM: Having a parent with Opioid Use Disorder (OUD) is a childhood adverse experience (ACE), magnified by other accompanying ACEs. Outcomes for these children tend to include developing mental illness and/or Substance Use Disorders themselves. Few studies address these children's experiences and needs. Without child-focused interventions to foster their resilience, generational ramifications of the OUD crisis will persist. METHODS: Nine children (ages 12-17), in Department of Social Services' custody, participated in this pilot study. The intervention delivered was Substance Abuse and Mental Health Administration's Children's Program Kit (CPK): Supportive Education for Children of Addicted Parents. Measures included OUD knowledge pre/posttests and the Behavioral and Emotional Rating Scale (BERS-2). FINDINGS: Findings from paired-samples t tests showed a significant increase in youth OUD knowledge from pre to posttest. Affective strength on the parent version (foster parent or social worker's perception of participant) and overall strength index on the youth's version BERS-2 increased significantly from pre to posttest. Career strength, a separate strength index, showed significant increased scores on both youth and parent BERS-2 versions pre to posttest. CONCLUSIONS: Results support Psychiatric Mental Health nurses to lead development and implementation of interventions, such as the CPK, with a strength-based approach to promote the knowledge and resilience of these children.

The impact of introducing the early warning scoring system and protocol on clinical outcomes in tertiary referral university hospital.

PURPOSE: The aim of this study was to evaluate the impact of a hospital protocol in response to patient deterioration in general wards, stratified using the national early warning score (NEWS), on primary patient outcomes of in-hospital mortality and percentage of patients transferred to the intensive care unit (ICU). PATIENTS AND METHODS: We conducted a prospective observational cohort study among adult medical patients admitted to a university hospital in Bangkok. A 4-month pre-protocol period (November 2015 to February 2016) was assigned to a control group and a protocol period (March 2016 to June 2016) was allocated to a protocol group. On admission, vital signs (respiratory rate, pulse rate, systolic blood pressure, and temperature), oxygen saturation, presence of oxygen supplementation, and neurological status were used to calculate NEWS. Patients were categorized as low, moderate, or high risk based on the NEWS. During protocol period, when patients' conditions are critical and they are at imminent risk, the NEWS detects the event and triggers a systematic response. The response enables closed monitoring and early treatment by expert physicians to rapidly stabilize and triage the patient to a location where services meet the patient's needs. Primary outcomes were compared between the pre-protocol and protocol groups using historical controls for the intervention, which is the availability of NEWS to staff and an associated escalation pathway. RESULTS: A total of 1,145 patients were included in the analysis: 564 patients in the pre-protocol group and 581 in the protocol group. The mean NEWS of patients at admission was higher in the protocol group than in the pre-protocol group (2.4±2.4 vs 1.77±2.158; P<0.001). There was no significant difference for in-hospital mortality and percentage of patients transferred to ICU between the groups. Among 95 (8.3%) patients at moderate risk, in-hospital mortality and ICU transfer percentage were lower in the protocol group than in the pre-protocol group (2.9 vs 15.4%; P=0.026; RR 0.188, 95% CI 0.037%-0.968% and 8.7 vs 26.9%; P=0.021; RR 0.322, 95% CI 0.12-0.87, respectively). CONCLUSION: Implementing the NEWS with the hospital protocol did not change the overall patient's outcomes.

Assistência às pessoas com transtornos mentais em conflito com a lei: perspectiva de gestores e profissionais de saúde Abstract / Care for people with mental disorders in conflict with the law: the perspective of health managers and professionals

Resumo O estudo teve como objetivo analisar a assistência às pessoas com transtornos mentais em conflito com a lei na perspectiva de gestores e profissionais de saúde. Trata-se de um estudo de caso, de abordagem qualitativa, realizado em janeiro de 2020, com 10 profissionais que atuavam no Hospital de Custódia e Tratamento Psiquiátrico do Estado do Rio Grande do Norte. Para coleta de dados, utilizou-se um questionário sociodemográfico e entrevista semiestruturada. O conteúdo textual decorrente das entrevistas foi submetido à análise textual lexicográfica, com auxílio do software IRAMUTEQ, e a análise dos dados foi realizada a partir de literatura pertinente. Emergiram três categorias: As mudanças nas relações de trabalho e o impacto na assistência; A organização da Rede de Cuidado; e A assistência intramuros e os entraves para desinstitucionalização. Conclui-se que a assistência às pessoas com transtornos mentais em conflito com a lei é influenciada pelas relações de trabalho; tem dificuldades relacionadas à estrutura física e à dinâmica das instituições; enfrenta entraves para garantir a desinstitucionalização, ao passo que fragmenta os vínculos e não implementa o Projeto Terapêutico Singular. Todavia, esforços têm sido empreendidos para articular a rede de cuidado de base territorial.

Abstract The study aimed to analyze the care of people with mental disorders in conflict with the law from the perspective of managers and health professionals. This is a qualitative case study conducted in January 2020 with 10 professionals working at the Psychiatric Custody and Treatment Hospital of the State of Rio Grande do Norte, Brazil. For data collection, a sociodemographic questionnaire and semi-structured interview were used. The textual content resulting from the interviews was submitted to lexicographic textual analysis, with the help of the IRAMUTEQ software and data analysis was performed based on pertinent literature. Three categories emerged: Changes in work relationships and impact on care; The organization of the Care Network; and Intra-wall care and barriers to deinstitutionalisation. It is concluded that the care for people with mental disorders in conflict with the law is influenced by work relationships; has difficulties related to the physical structure and dynamics of institutions; it faces obstacles to ensure deinstitutionalization while fragmenting ties and not implementing the Singular Therapeutic Project. However, efforts have been made to articulate the territorial-based care network.

Liderança e comportamento empoderador: compreensões de enfermeiros-gerentes na Atenção Primária à Saúde / Liderazgo y comportamiento empoderador: percepciones de enfermeros-gerentes en la Atención Primaria de Salud / Leadership and empowering behavior: understandings of nurse managers in Primary Health Care

Resumo Objetivo Conhecer o comportamento empoderador do enfermeiro em sua prática gerencial no contexto da Atenção Primária à Saúde. Métodos Pesquisa exploratória de caráter qualitativo realizada com enfermeiros-gerentes que atuam em Unidades Básicas de Saúde em um município do estado de São Paulo, Brasil. Foram conduzidas entrevistas semiestruturadas para coleta de dados e o conteúdo das entrevistas foi transcrito na íntegra. Utilizou-se a saturação teórica de dados para o encerramento da coleta que se deu no sétimo participante. O referencial da análise de conteúdo guiou a organização do corpus qualitativo em temas e subtemas. Resultados O enfermeiro-gerente como líder utiliza do comportamento empoderador para interpretar suas percepções e suas atitudes, para influenciar positivamente o trabalho em equipe e mediar conflitos. Dimensionamento de pessoal e dificuldades em realizar reuniões de equipe e em compartilhar os processos decisórios geram desafios que tensionam a efetivação do comportamento empoderador. Conclusão Aspectos relacionados ao trabalho gerencial do enfermeiro-líder nas Unidades Básicas de Saúde são compreendidos como comportamento empoderador e os desafios para sua efetivação relacionaram-se à organização e ao planejamento do processo de trabalho da Atenção Primária à Saúde.

Resumen Objetivo Conocer el comportamiento empoderador de los enfermeros en su práctica gerencial en el contexto de la Atención Primaria de Salud. Métodos Estudio exploratorio de carácter cualitativo realizado con enfermeros-gerentes que trabajan en Unidades Básicas de Salud en un municipio del estado de São Paulo, Brasil. Para la recopilación de datos, se realizaron entrevistas semiestructuradas y se transcribió su contenido completamente. Para finalizar la recopilación, se utilizó la saturación teórica de datos, que sucedió con el séptimo participante. El marco referencial del análisis de contenido guio la organización del corpus cualitativo en temas y subtemas. Resultados Los enfermeros-gerentes como líderes utilizan el comportamiento empoderador para interpretar sus percepciones y sus actitudes, para influir positivamente el trabajo en equipo y para mediar conflictos. El dimensionamiento del personal y las dificultades para realizar reuniones de equipo y compartir los procesos decisorios generan desafíos que tensionan la materialización del comportamiento empoderador. Conclusión Los aspectos relacionados con el trabajo gerencial del enfermero líder en las Unidades Básicas de Salud son percibidos como un comportamiento empoderador, y los desafíos para su materialización se relacionan con la organización y la planificación del proceso de trabajo de la Atención Primaria de Salud.

Abstract Objective To understand the empowering behavior of nurses in their management practice in the Primary Health Care context. Methods Exploratory qualitative study of nurse managers working in Basic Health Centers in a city in the state of São Paulo, Brazil. Semi-structured interviews were conducted for data collection and the content of interviews was fully transcribed. Data collection was ended after reaching theoretical data saturation in the seventh participant. The content analysis framework guided the organization of the qualitative corpus into themes and sub-themes. Results As leaders, nurse managers use empowering behavior to interpret their perceptions and attitudes in order to positively influence teamwork and mediate conflicts. Staff sizing and difficulties in holding team meetings and sharing decision-making processes generate challenges that create tension in the implementation of empowering behavior. Conclusion Aspects related to the management work of nurse leaders in Basic Health Centers are understood as empowering behavior and the challenges for its implementation are related to the organization and planning of the work process in Primary Health Care.

The impact of a multifaceted intervention including sepsis electronic alert system and sepsis response team on the outcomes of patients with sepsis and septic shock.

BACKGROUND: Compliance with the clinical practice guidelines of sepsis management has been low. The objective of our study was to describe the results of implementing a multifaceted intervention including an electronic alert (e-alert) with a sepsis response team (SRT) on the outcome of patients with sepsis and septic shock presenting to the emergency department. METHODS: This was a pre-post two-phased implementation study that consisted of a pre-intervention phase (January 01, 2011-September 24, 2012), intervention phase I (multifaceted intervention including e-alert, from September 25, 2012-March 03, 2013) and intervention phase II when SRT was added (March 04, 2013-October 30, 2013) in a 900-bed tertiary-care academic hospital. We recorded baseline characteristics and processes of care in adult patients presenting with sepsis or septic shock. The primary outcome measures were hospital mortality. Secondary outcomes were the need for mechanical ventilation and length of stay in the intensive unit and in the hospital. RESULTS: After implementing the multifaceted intervention including e-alert and SRT, cases were identified with less severe clinical and laboratory abnormalities and the processes of care improved. When adjusted to propensity score, the interventions were associated with reduction in hospital mortality [for intervention phase II compared to pre-intervention: adjusted odds ratio (aOR) 0.71, 95% CI 0.58-0.85, p = 0.003], reduction in the need for mechanical ventilation (aOR 0.45, 95% CI 0.37-0.55, p < 0.0001) and reduction in ICU LOS and hospital LOS for all patients as well as ICU LOS for survivors. CONCLUSIONS: Implementing a multifaceted intervention including sepsis e-alert with SRT was associated with earlier identification of sepsis, increase in compliance with sepsis resuscitation bundle and reduction in the need for mechanical ventilation and reduction in hospital mortality and LOS.

Vivenciando a Rede: Caminhos para a Formação do Médico no Contexto do SUS / Experiencing the Network: Paths for Medical Training in the Context of the SUS

RESUMO Os cursos de educação médica têm implementado disciplinas e módulos que aproximem os discentes da realidade da saúde nacional, a fim de se adequarem às crescentes necessidades de reorganização da formação médica. O presente artigo relata uma experiência de acadêmicos de Medicina da Universidade Estadual de Santa Cruz (UESC) com as atividades e ações incluídas no módulo de Gestão e Rede de Atenção à Saúde, parte da Prática de Integração Ensino-Serviço-Comunidade (PIESC), como proposta de reorientação do currículo na aquisição de habilidades de liderança e gerenciamento de recursos físicos e humanos em saúde. A proposta foi inserir os discentes em diferentes níveis de complexidade tecnológica do SUS a fim de contextualizar o estudo da Rede de Atenção à Saúde (RAS) por meio de vivências e pesquisa-ação em serviços de saúde situados nos diferentes níveis de atenção. Para isso, foram realizadas entrevistas semiestruturadas com profissionais e usuários em cada ambiente visitado. Tais vivências ampliaram a visão dos acadêmicos sobre os serviços de saúde, possibilitando um melhor entendimento da estruturação da RAS, bem como um dimensionamento dos entraves encontrados nos diferentes cenários e proporcionando uma experiência in loco das críticas e dificuldades apresentadas e vividas por usuários e profissionais. Percebeu-se que não há resolutividade dos problemas de saúde dos usuários nos serviços, bem como existe uma falta de entendimento destes acerca de seus direitos e da continuidade da atenção à saúde nos diferentes níveis de atenção. Explicitou-se que as instâncias primárias de atenção não funcionam como porta de entrada adequada, o que culmina com a desestruturação da RAS observada. A experiência relatada neste artigo demonstrou um modo dinâmico de abordar a temática da Gestão e Rede de Atenção à Saúde, além de contribuir para a formação do estudante de Medicina, já que possibilitou um melhor entendimento da rede quanto às práticas em saúde e às dimensões do processo saúde-doença implicados na gestão do SUS.

ABSTRACT Medical courses in Brazil have implemented subjects and modules that aim to bring students closer to actual national health concerns, as one way of adapting to the growing needs for medical training reorganization. Thus, this article reports on the experience of medical students at the Universidade Estadual de Santa Cruz (UESC) [State University of Santa Cruz] with activities and actions included in the Health Care Network and Management module, part of the Teaching-Service-Community Intergration Practice (PIESC), as a proposal for the reorientation of the curriculum and acquisition of leadership skills and management of physical and human resources in health. The proposal was to insert the students at different levels of technological complexity of the Unified Health System (SUS) in order to contextualize the study of the Health Care Network (RAS) through experiences and action research in health services located at different care levels. Semi-structured interviews with professionals and users were therefore performed in each visited environment. These experiences served to broaden the students' vision of health care networks, enabling a better understanding of how the services are structured, as well as of the magnitude of the obstacles found in different scenarios, providing an in loco experience of the criticisms and difficulties faced by users and professionals. It was noticed that user health problems are often not resolved within the health care services, and the users lack understanding of their health rights. A lack of continuity of the health care was also observed through the various health care levels. Thus, it is concluded that the instances of primary care fail to offer adequate gateway services, culminating in the breakdown of the observed network. The experiment reported in this article demonstrated a dynamic way to approach the issue of Health Care Network Management, contributing to medical student training, as it enabled a better understanding of the network in terms of the health practices and the dimensions of the health-disease process involved in the management of the SUS.

Segmentación y comportamiento de lealtad de los pacientes: un análisis clúster en los departamentos de salud de la Comunidad Valenciana / Segmentation and Patient Loyalty: A Cluster Analysis of the Health Service Departments in the Valencian Community / Segmentação e comportamento de lealdade dos pacientes: uma análise cluster nos departamentos de saúde da Comunidade Valenciana

Resumen En un marco sanitario de fragmentación territorial y cohabitación de gestión pública con colaboración público-privada, tiene sentido analizar y clasificar los departamentos sanitarios, atendiendo a múltiples objetivos: conocer el comportamiento real de los pacientes cuando pueden elegir dónde ser atendidos, adaptar la cartera de servicios a las preferencias del paciente y organizar la asistencia sanitaria desde una óptica territorial, considerando si afecta el modelo de gestión. Se utilizan datos secundarios (más de dos millones) en la Comunidad Valenciana, con un análisis clúster del comportamiento de lealtad (captación, retención y deserción). Esta metodología permite la reagrupación por similitud de los departamentos, explicando su homogeneidad entre sí y heterogeneidad respecto a otros. Se muestra la bondad de este análisis en el sector sanitario. Asimismo, la clasificación obtenida supone una guía para la gestión estratégica de los servicios sanitarios (a nivel macro y micro) y ahonda en el debate de la colaboración público-privada.

Abstract Under a health service framework marked by the territory segmentation and the coexistence of public administration and public-private ventures, it makes sense to analyze and classify the health service departments by considering the following objectives: to know the way patients actually behave when the choice of the service place is up to themselves; to adapt the service offer to the patient's preferences; and to organize health service based on the territory location, thus considering its influence on the management model. Secondary data from the Valencian Community (over two million data) are used in the cluster analysis of the patient loyal behavior (entering, retention and drop out). This methodology enables the department clustering based on their similarities, thus explaining the homogeneity and heterogeneity with each other. This analysis shows to be useful for the said health service sector. In addition, the resulting classification provides a guide for the strategic management of the health services (at the macro and micro levels) and goes deeper in the debate about public-private ventures.

Resumo Em um marco sanitário de fragmentação territorial e coabitação de gestão pública com parceria público-privada faz sentido analisar e classificar os departamentos sanitários, atendendo objetivos múltiplos: conhecer o comportamento real dos pacientes quando puder eleger onde eles serem atendidos, adaptar o portfolio de serviços às preferencias do paciente e organizar a assistência sanitária desde una ótica territorial, considerando se afeta o modelo de gestão. Utilizam-se dados secundários (mais de dois milhões) na Comunidade Valenciana, com análise cluster do comportamento de lealdade (recrutamento, retenção e deserção). Essa metodologia permite a reagrupação por semelhança dos departamentos, explicando a sua homogeneidade entre se e a heterogeneidade em relação aos demais. Demonstra-se a bondade desta análise no setor sanitário. Da mesma forma, a classificação obtida supõe uma guia para a gestão estratégica dos serviços sanitários (no nível macro e micro) e aprofunda o debate da parceria público-privada.

Implicações da acreditação para a gestão do serviço hospitalar / Acreditación de las implicaciones para la gestión de los servicios de hospital / Implications of the accreditation for the management of hospital service

Objetivo: analisar as implicações da acreditação hospitalar para a gestão do serviço. Métodos: estudo de caso com abordagem qualitativa, realizado com 12 gerentes de um hospital acreditado. Os dados foram coletados por meio de entrevistas, com roteiro semi estruturado, e analisados pela Análise de Conteúdo. Resultados: foram identificadas repercussões positivas: padronização, organização do serviço, melhoria contínua, trabalho sistêmico e intersetorial. E negativas: cobrança para cumprir meta e alcançar resultados, estresse e sobrecarga de trabalho. Conclusão: A acreditação traz mudanças para a gestão do serviço, para os profissionais e para a prática gerencial. Os profissionais precisaram adquirir uma habilidade para conciliar interesses da instituição e dos profissionais.

Objective: to analyze the implications of hospital accreditation for the management of the service. Method: case study with qualitative approach, conducted with 12 managers of accredited hospital. Data were collected through interviews with semistructured report, and analyzed by content analysis. Results: positive effects have been identified: standardization, service organization, continuous improvement, systemic and intersectoral work. And the negative effects are: requirement to fulfill goaland to achieve results, stress, work overload. Conclusion: accreditation brings changes to service management, for professional and managerial practice. The professionals had to acquire an ability to reconcile interests of the institution and professionals.

Objetivo: analizar las implicaciones de acreditación de hospitales para la gestión del servicio. Metodo: estudio de caso con unenfoque cualitativo, realizado con 12 directivos de un hospital acreditado. Los datos fueron recolectados a través de entrevistas con semi-estructurada y analizados por análisis de contenido. Resultados: efectos positivos se han identificado: la normalización, la organización de servicio, mejora continua, trabajo sistémico e intersectorial. Y negativo: la carga de cumplir el objetivo y lograr resultados, estrés, la sobrecarga. Conclusión: Acreditación trae cambios en la gestión del servicio , para la práctica profesional y degestión. Los profesionales tuvieron que adquirir una capacidad de conciliar los intereses de la institución y profesionales.

Management in primary health care: discourses about the search for respiratory symptomatics of tuberculosis / Gestión en la atención primaria en la salud: discursividades sobre la búsqueda de sintomáticos respiratorios de la tuberculosis / Gerência na atenção primária à saúde: discursividades sobre a busca de sintomáticos respiratórios da tuberculose

ABSTRACT The study aimed to analyze the discourse of Primary Health Care managers about the search for respiratory symptomatics as an epidemiological surveillance action of tuberculosis. A qualitative study was undertaken, guided by the theoretical and analytical framework of French Discourse Analysis. Data were produced in May 2012 through semi-structured interviews with 14 subjects. Two discursive blocks were produced: marks of power in the execution of the search for respiratory symptomatics; resistance strategies in the search for respiratory symptomatics. Discursive positions were grounded in the traditional management model, making it difficult to incorporate the search for respiratory symptomatics as a participatory action that integrates health staff, managers and the community. Insufficient human resources, workload and rigor in achieving goals favor postures of immobility among the professionals. It is concluded that the managerial work outlined in the health surveillance model encourages the mobilization of practices that contribute to qualify the search for respiratory symptomatics in Primary Health Care.

RESUMEN El estudio objetivó analizar los discursos de gerentes de Atención Primaria de Salud en la búsqueda de sintomáticos respiratorios como acción epidemiológica de vigilancia de la tuberculosis. Estudio cualitativo, basado en el marco teórico y analítico del Análisis del Discurso de matriz francesa. Los datos fueron producidos en Mayo de 2012 por medio de entrevista semiestructurada con 14 sujetos. Se produjeron dos bloques de discurso: los rastros de poder en la ejecución; estrategias de resistencia en la búsqueda de síntomas respiratorios. Posiciones discursivas basadas en el modelo de gestión tradicional hacen que sea difícil de incorporar la búsqueda de sintomáticos respiratorios como la acción participativa que integre el personal de salud, los administradores y la comunidad. Recursos humanos insuficientes, carga de trabajo y el rigor en el logro de metas proporcionan posturas inmovilidad de los profesionales. Se considera que el trabajo gerencial basado en el modelo de vigilancia de la salud podría fomentar la movilización de prácticas que contribuyan a calificar la búsqueda de sintomáticos respiratorios en la Atención Primaria de Salud.

RESUMO Objetivou-se analisar discursos de gerentes da Atenção Primária à Saúde sobre a busca de sintomáticos respiratórios como ação de vigilância epidemiológica da tuberculose. Estudo qualitativo, norteado pelo referencial teórico-analítico da Análise de Discurso de matriz francesa. Os dados foram produzidos em maio de 2012, por meio de entrevistas semidirigidas com 14 sujeitos. Produziram-se dois blocos discursivos: vestígios de poder na efetivação da busca de sintomáticos respiratórios; estratégias de resistência na busca de sintomáticos respiratórios. Posições discursivas pautadas no modelo de gestão tradicional, dificultam a incorporação da busca de sintomáticos respiratórios como ação participativa que integre equipe de saúde, gestores e comunidade. Insuficiência de recursos humanos, sobrecarga de trabalho e rigorosidade no alcance de metas favorecem posturas de imobilismo dos profissionais. Conclui-se que o trabalho gerencial pautado no modelo de vigilância em saúde estimule práticas de mobilização que contribuam na qualificação da busca de sintomáticos respiratórios na Atenção Primária à Saúde.

Gerenciamento em saúde: o olhar de trabalhadores da saúde da família rural / Gestión en salud: la óptica de trabajadores de la salud de la familia rural / Management in health: the workers look of a rural family health

RESUMO O gerenciamento do trabalho em saúde na Estratégia Saúde da Família democrático e participativo consiste em um dos grandes desafios desse nível de atenção à saúde. Nesse sentido, desenvolveu-se este estudo qualitativo com o objetivo de analisar as concepções de profissionais da Estratégia Saúde da Família sobre gerenciamento do trabalho em saúde. Foram realizadas entrevistas semiestruturadas com 10 profissionais de uma Unidade de Saúde da Família rural em cidade de médio porte do interior de São Paulo. Os dados foram analisados por meio da análise de conteúdo temático-categorial. Obtiveram-se três categorias de análise: Organização do trabalho em saúde para o alcance de metas; O gerenciamento marcado pela racionalidade e com foco no enfermeiro; Facilidades e dificuldades que permeiam a construção de espaços coletivos na Estratégia Saúde da Família. Considera-se que existe a necessidade de se atentar para o gerenciamento do trabalho na Estratégia Saúde da Família, com a necessidade de que os sujeitos se corresponsabilizem pelas pactuações e decisões tomadas em equipe, garantindo a fala e a escuta de todos. Além disso, é relevante que haja avaliação processual das ações implementadas e dos pactos realizados pelos profissionais de saúde.

RESUMEN La gestión del trabajo en salud en la Estrategia Salud de la Familia (ESF) democrática y participativa consiste en uno de los grandes retos de este nivel de atención a la salud. En este sentido, hemos desarrollado este estudio cualitativo con el objetivo de analizar las concepciones de profesionales de la ESF sobre la gestión del trabajo en salud. Fueron realizadas entrevistas semiestructuradas con 10 profesionales de una Unidad de Salud de la Familia rural de una ciudad de tamaño mediano en el interior de São Paulo-Brasil. Los datos fueron analizados mediante el análisis de contenido categorial temático. Se obtuvieron tres categorías de análisis: La organización del trabajo en salud para el logro de los objetivos; La gestión marcada por la racionalidad y con enfoque en el enfermero; Facilidades y dificultades que permean la construcción de espacios colectivos en la ESF. Se considera que existe una necesidad de atención en cómo se ha llevado a cabo el trabajo de gestiónenla ESF, con la necesidad de que los sujetos se corresponsabilicen por los pactos y las decisiones del equipo, asegurando el habla y la escucha de todos. Además, es importante que exista un proceso de evaluación de las acciones realizadas y los pactos realizados por profesionales de salud.

ABSTRACT The management of health work in the Family Health Strategy (FHS) democratic and participatory consists of one of the great challenges of this level of health care. In this sense, we developed this qualitative study aimed to analyze the professional conceptions of the Family Health Strategy (FHS) on management of health work. Semi-structured interviews were conducted with 10 professionals from a rural family health unit of a medium-sized city in the interior of São Paulo. Data were analyzed using thematic-categorical content analysis. Obtained three categories of analysis: Organization of health work for the achievement of goals; The management marked by rationality and focused on the nurse; Facilities and difficulties that permeate the construction of collective spaces in the FHS. It is considered that there is a need to pay attention on how the management work has taken place in the FHS, with the need for the wareness of the individuals by pacts and team decisions, ensuring the speaking and listening all. Moreover, it is important that there is a process evaluation of the implemented actions and pacts made by health professionals.