A garantia do acesso dos usuários do Sistema Único de Saúde (SUS) em todos os níveis de atenção em tempo adequado e a criação de fluxos de assistência à saúde que opere de forma sincronizada são uns dos grandes desafios do SUS. O HCFMRP-USP oferta serviços de nível terciário dentro do sistema, sendo referência dentro de sua Regional de Saúde trabalha para otimizar suas vagas ofertadas aos Departamentos Regionais de Saúde e absorver o maior número possível de pacientes que necessitam de atendimento terciário. Objetivo: Avaliar o aproveitamento das vagas de consultas para novos pacientes ofertadas pelo HCFMRP - USP aos Departamentos Regionais de Saúde de sua região de abrangência, no período de 2006 a 2014. Metodologia: Foi realizado um estudo descritivo com dados secundários do banco de dados do HCFMRP-USP, a partir das informações do Serviço de Agendamento e Controle de Pacientes Ambulatoriais. Foram calculadas no período de 2006 até 2014, a Taxa de Agendamento, Taxa de Falta, Taxa de adequação da Referência e Taxa de Aproveitamento Global. Resultados: A taxa geral de agendamento foi 76%, a taxa de falta de pacientes novos teve a média de 17%, a Taxa média de Adequação da Referência foi de 92%. A taxa de aproveitamento global foi 57%, ano de 2014 das 37.830 vagas disponibilizadas pelo HCRP apenas 21.170 foram efetivamente aproveitadas. CONCLUSÕES: As iniciativas para o HCFMRP-USP se consolidar como um hospital terciário vem sendo gradativamente concretizadas, todas as taxas avaliadas tiveram uma melhora significativa se compararmos com o estudo anteriormente realizado que avaliou os anos de 2000-2005, mas ainda existem muitos desafios. Os gestores precisam avaliar os dados e buscarem mudanças em suas práticas de gestão, sendo necessários investimentos na formação recursos humanos e na integração entre gestores para que seja possível o integral aproveitamentos das vagas disponibilizadas. / Ensuring access of users of the Unified Health System (UHS) at all levels of care in a timely manner and the creation of health care flows that operate synchronously are one of the great challenges of UHS. The HCFMRP-USP offers tertiary services within the system, being a reference within its Regional Health activity to optimize their vacancies offered to the Regional Health Departments and the largest possible number of patients who need tertiary care. Objective: Evaluate the use of vacancies consultations for new patients offered by HCFMRP - USP to Regional Departments of Health within the respective coverage area in the period 2006-2014. Methodology: A descriptive study of secondary data from HCFMRP- USP database was conducted from information of the Scheduling and Ambulatory Patient Control Service. There were calculated in the period of 2006 until 2014: the Schedule Rate, Lack Rate, Adequacy Rate Reference and Global Utilization Rate. Results: The overall Schedule Rate was 76%, the Lack Rate of new patients had an average of 17%, the average Reference Adequacy Rate 92%. The Global Utilization Rate was 57%, in the year of 2014 37,830 vacancies provided by HCFMRP-USP only 21,170 were actually utilized. Conclusions: The initiatives for HCFMRP-USP consolidate as a tertiary hospital has been gradually implemented, all measured rates had a significant improvement when compared to the previously conducted study that evaluated the years 2000-2005, but there are still many challenges. Managers need to evaluate the data and seek changes in their management practices and the necessary investments in training human resources and integration of managers for the full exploitations of available vacancies is possible.

The Johnson City Community Health Center is one of over 1200 community health centers serving over 22 million patients across the United States. Community health centers primarily serve patients with low income or without health insurance, but most serve all the members of their communities. These centers provide many services and treat health problems in a holistic manner in order to improve the health of their communities and also allow the members of those communities to progress. The Johnson City Community Health Center is compared to successful CHCs from across the nation to determine if it has characteristics to be successful in this community. A SWOT Analysis is conducted by evaluating the Marketing Mix, or the Product, Price, Placement, and Promotion, of the center and also by examining the Political, Economic, Social, and Technological environments it operates in. This research determines the internal Strengths and Weaknesses and external Opportunities and Threats of the Johnson City Community Health Center and concludes that it does have the characteristics needed to be successful in the community. This research can be used by center management to improve services, but it can also be used by other researchers to continue evaluations of community health centers across the nation.

Decades of research have shown that there are significant advantages to maintaining close communicative and collaborative relationships between primary care and behavioral health providers. Fiscal, structural, and systemic barriers, however, often restrict the degree to which such interprofessional collaboration can occur. In the present study the authors examined relationships between primary care clinics in the Appalachian region’s characteristics (i.e., clinic type, rurality, and clinic size), barriers (i.e., fiscal, structural, and systemic) reported to using increased collaboration, and the level of collaboration used at a particular clinic. For the present study 136 surveys were completed by providers working in primary care practices across the Appalachian region of Tennessee. The results showed that only about one fifth of the primary care clinics in Appalachian Tennessee reported engaging in moderate to high levels of primary care behavioral health (PCBH) collaboration (e.g., colocated or integrated models of care). Among community health clinics, however, nearly half reported moderate or high levels of collaboration. The findings of this study underscore the importance policy change (e.g., changes in reimbursement patterns, increases in incentives, introduction of PCBH models in training programs) in facilitating the uptake of high levels of PCBH collaboration in Appalachian Tennessee (especially in regards to nonpublicly funded clinics). Further, the methodology used in this study could provide policymakers and researchers in other regions of the U.S. with a means for obtaining baseline data regarding local trends in PCBH collaboration and could serve as first step in developing a standardized methodology for comparing the overall uptake of PCBH collaboration models across regions.

University of Macau / Faculty of Social Sciences and Humanities / Department of Government and Public Administration

The purposes of this cross-sectional and internet mixed methods study were: (a) to explore the level of structural empowerment (SEP), psychological empowerment (PE), participation in decision making (PDM), their relationships, and their predictors among Taiwanese nurses, and (b) to explore the influence of contextual factors (culture and gender) on the nurses’ perception on their work environment and PDM based on the feminist perspective and Laschinger’s expanded empowerment model. This study included an Internet questionnaire survey (quantitative) and a Web-based online forum (qualitative). A convenient sample of 163 Taiwanese registered nurses (a) who are currently working full time in health care institutions for at least 3 months, (b) can read and write Chinese on the computer, and (c) have access to the Internet was recruited and completed the internet survey. Among them, 20 completed the online forum discussion topics. The findings of the internet survey indicated that participants had moderate level of SEP, high-moderate level of PE and low level of PDM. Personal characteristics, such as age, education, and work experience, did not significantly correlate to Taiwanese nurses’ empowerment. However, the work structures, such as workload, types of hospitals, and work units, were significantly related to Taiwanese nurses’ empowerment and PDM. PE was a mediator between SEP and PDM, which indicated that with increased access to workplace empowerment structures, nurses perceived better personal empowerment, which in turn increased nurses’ PDM. In the online forum, two themes were discovered: (a) foot-binding unto nursing and (b) not open up. The first theme indicated that certain stereotypes regarding gender roles in Taiwanese society were restraints to the growth of nursing. Due to the stereotypes, nurses were located in the lower social status and developed powerless behaviors. The second theme indicated that communication among nurses was not sufficient, which might stem from the influence of Confucianism, collectivism, and power distance. The findings in this study extend our understanding of the empowerment and PDM among Taiwanese nurses within the context of gender and culture. / text

A demanda por procedimentos médicos gerados pela transformação dos perfis etários e de morbi-mortalidade das populações tem forçado uma escalada contínua dos custos da assistência que atingem limites críticos em relação à disponibilidade de recursos. É neste contexto onde a priorização é a regra e o desperdício inaceitável, que métodos de otimização vem sendo desenvolvidos, dentre eles o “Audit and feedback”. De um total de 176 médicos de uma regional de cooperativa, 130 constituíram a amostra para estudo Quase-experimento com total de dois anos de seguimento (2004- 2005). As informações tratavam do “Índice de Solicitações de Serviços Auxiliares de Diagnose e Terapia” (Is SADT) e eram fornecidas de modo que cada profissional sabia qual era a sua posição dentro do grupo da mesma especialidade, mas não tinha condições de identificar os demais. Apesar do número absoluto de SADT realizados ter sido no mínimo o quádruplo do esperado para a população de beneficiários, o retorno de informações visando à conscientização pelo método “Audit and Feedback” não foi capaz de provocar diferenças significas nas solicitações de procedimentos nos diferentes grupos de médicos, conforme constatado após análise estatística. Não se evidenciou nenhuma relação significativa das variáveis independentes deste estudo (sexo, tempo de formado e tempo de cooperado), com os Índices de Solicitações de SADT dos médicos que estavam acima ou abaixo da mediana nos diferentes estratos. Persiste como desafio, a comprovação do fator ou fatores responsáveis por esta resposta. Propõe-se um conjunto de ações a serem associadas, uma vez que o processo de conscientização isoladamente foi inócuo. / Changing age, morbidity and mortality profiles of populations have caused an increase in the demand for medical procedures and a continuous increase in the cost of health services that is reaching limits in terms of available resources. It is in the context of prioritization as the rule and waste as unacceptable that optimization methods have been developed, among them “audit and feedback”. Of a total of 176 physicians of a regional cooperative, 130 were included in the study sample. The procedure ordering behaviour of each physician in the sample was monitored during all of 2004 and 2005. Audit: each month the an “index of solicitations for auxiliary diagnostic and treatment services”, or SADT, basically the average number of orders per consultation for the month, was calculated for each physician. Feedback: SADT for all participating physicians, organized by speciality and rank, were sent to each participating physician. The results were presented in a way that each physician could locate themselves in the ranking without being able to identify where any other physicians placed in the ranking. Despite absolute number of SADT on average fourfold that expected for the demographic profile of the population being served, statistical analysis of the results showed that the “Audit and Feedback” optimization method did not have a significant effect on the ordering behaviour of physicians or in the sample, un-grouped or grouped by speciality, gender, time in practice or time in the cooperative. Nor did grouping according the whether and individual physician was initially above or below the median SADT reveal any significant effect of the method on ordering behaviour. The results do show that factors other than how a physician's individual SADT compares to that of his or her peers, determines their procedure ordering behaviour. Identifying these factors remains an important challenge in the context of health services optimization.

This thesis was born from a concern the researcher had with regard to negative reports in the media emanating from 4 babies that died at Cecilia Makiwane Hospital Peadiatric ICU unit due to power supply failure. The most significant of these negative reports was in 2007 when the Daily Dispatch ran a series of articles regarding what they termed avoidable deaths over the last 14 years. The ease with which staff communicated with the media together with the high absenteeism rate and high turnover was a cause for concern. When the researcher analysed the history of the problem, it immerged from the respondents’ responses that the rationalistion process undertaken by the Eastern Cape Department of Health (ECDoH) was a significant root cause to the problem. The literature review focused on three areas viz.: Organisational Culture, Organisational Change, Foundations of Satisfaction. This focus was used to confine the problem to a manageable project but secondly each of the aspects are interwoven. Routledge (2010) notes that culture is the reflection of the values advocated by a founder or leader by way of his/her day to day actions. This is done by the leader creating a perception or viewpoint that assists the employees to achieve the organisation’s mission, vision and goals. In any organisation change is a constant and it needs to be effectively managed. With government institutions like the East London Hospital Complex (ELHC) directives come from the top and are implemented by an unprepared and untrained leadership and management cadre and clear communication of vision and objective of the desired outcomes never happens. The aim of the research was to: describe the existing Organisational Culture present at ELHC (Perform an organisational diagnosis); describe the impact of change (rationalisation) and to analyze why there was such a high staff turnover. It is clear from the results of the survey conducted that significant dissatisfaction prevailed relating to how the institution was managed. Dissatisfaction amongst the health professionals was general but also specific to the following: leadership and management issues, fairness, remuneration and lack of resources. The recommendations therefore focused on developing management and leadership within the proposal of Dubrin’s model (2001).

A demanda por procedimentos médicos gerados pela transformação dos perfis etários e de morbi-mortalidade das populações tem forçado uma escalada contínua dos custos da assistência que atingem limites críticos em relação à disponibilidade de recursos. É neste contexto onde a priorização é a regra e o desperdício inaceitável, que métodos de otimização vem sendo desenvolvidos, dentre eles o “Audit and feedback”. De um total de 176 médicos de uma regional de cooperativa, 130 constituíram a amostra para estudo Quase-experimento com total de dois anos de seguimento (2004- 2005). As informações tratavam do “Índice de Solicitações de Serviços Auxiliares de Diagnose e Terapia” (Is SADT) e eram fornecidas de modo que cada profissional sabia qual era a sua posição dentro do grupo da mesma especialidade, mas não tinha condições de identificar os demais. Apesar do número absoluto de SADT realizados ter sido no mínimo o quádruplo do esperado para a população de beneficiários, o retorno de informações visando à conscientização pelo método “Audit and Feedback” não foi capaz de provocar diferenças significas nas solicitações de procedimentos nos diferentes grupos de médicos, conforme constatado após análise estatística. Não se evidenciou nenhuma relação significativa das variáveis independentes deste estudo (sexo, tempo de formado e tempo de cooperado), com os Índices de Solicitações de SADT dos médicos que estavam acima ou abaixo da mediana nos diferentes estratos. Persiste como desafio, a comprovação do fator ou fatores responsáveis por esta resposta. Propõe-se um conjunto de ações a serem associadas, uma vez que o processo de conscientização isoladamente foi inócuo. / Changing age, morbidity and mortality profiles of populations have caused an increase in the demand for medical procedures and a continuous increase in the cost of health services that is reaching limits in terms of available resources. It is in the context of prioritization as the rule and waste as unacceptable that optimization methods have been developed, among them “audit and feedback”. Of a total of 176 physicians of a regional cooperative, 130 were included in the study sample. The procedure ordering behaviour of each physician in the sample was monitored during all of 2004 and 2005. Audit: each month the an “index of solicitations for auxiliary diagnostic and treatment services”, or SADT, basically the average number of orders per consultation for the month, was calculated for each physician. Feedback: SADT for all participating physicians, organized by speciality and rank, were sent to each participating physician. The results were presented in a way that each physician could locate themselves in the ranking without being able to identify where any other physicians placed in the ranking. Despite absolute number of SADT on average fourfold that expected for the demographic profile of the population being served, statistical analysis of the results showed that the “Audit and Feedback” optimization method did not have a significant effect on the ordering behaviour of physicians or in the sample, un-grouped or grouped by speciality, gender, time in practice or time in the cooperative. Nor did grouping according the whether and individual physician was initially above or below the median SADT reveal any significant effect of the method on ordering behaviour. The results do show that factors other than how a physician's individual SADT compares to that of his or her peers, determines their procedure ordering behaviour. Identifying these factors remains an important challenge in the context of health services optimization.

Esta pesquisa propõe um instrumento para avaliação de serviços hospitalares com base em critérios de assistência, infraestrutura e práticas de gestão, como forma de contribuir para o gerenciamento dos negócios em saúde no Brasil. Desta forma, identificou-se que os planos/seguros de saúde e os hospitais brasileiros não possuem um instrumento abrangente e adequado para aferir a qualidade dos serviços hospitalares multiespecializados, disponibilizados aos seus clientes, nos três aspectos fundamentais citados acima. Consequentemente, não há diferenciação, nas tabelas de remuneração contratadas entre planos/seguros de saúde e hospitais, que seja fundamentada em critérios técnicos e que estimulem a concorrência entre os prestadores de serviços nos quesitos eficiência, qualidade e custos dos serviços prestados aos clientes/pacientes. Através da revisão bibliográfica, buscou-se compreender a dinâmica econômica do setor saúde no Brasil, o relacionamento comercial entre os participantes, os métodos de classificação hospitalar disponíveis no mercado brasileiro, os critérios legais e técnicos para avaliação da assistência médicohospitalar, da infraestrutura hospitalar e das práticas de administração hospitalar. Obteve-se, ao final desta pesquisa, uma ferramenta de diagnóstico precisa, do tipo check list, para mensurar as condições técnicas dos serviços hospitalares disponibilizados aos clientes das instituições avaliadas. / This research proposes a tool for evaluation of hospital services on the basis of assistance, infrastructure and management practices as a way to contribute to the health care management in Brazil. Thus, we identified that Brazilians prepaid health plans/health insurance and hospitals do not have a comprehensive and appropriate instrument for measuring the quality of multi-specialist hospital services, available to their customers for the three aspects above mentioned of this hospital services. Consequently, there is no differentiation in price scales between contracted prepaid health plans/health insurance and hospitals that are based on technical criteria and to encourage competition among service providers regarding to efficiency, quality and cost of services to clients/patients. Through literature review we sought to understand the economic dynamics of the health care management field in Brazil, the commercial relationship between participants, the methods of hospital classification available in Brazil, legal and technical criteria for evaluation of medical assistance, the hospital infrastructure and practices of hospital administration. It was obtained at the end of this research a diagnostic tool, of the check list type, for measuring the technical conditions of hospital services provided to clients by the evaluated institutions.

O conceito de segurança nasceu com o homem primitivo ao lutar diariamente para sobreviver contra os ataques de predadores. Com o passar dos anos foram surgindo parâmetros de sobrevivência e segurança em quase todas as atividades de trabalho. Na área de saúde e de enfermagem este tema tem mobilizado esforços das organizações de saúde no sentido de evitar falhas nos processos de cuidado que possam causar eventos adversos aos pacientes. Trata-se de uma pesquisa exploratória, descritiva, com abordagem qualitativa, com o objetivo de analisar a aplicação do checklist da cirurgia segura no centro cirúrgico para a segurança do paciente. O estudo foi conduzido utilizando-se a técnica de grupos focais e métodos fotográficos de pesquisa, na perspectiva do pensamento ecológico restaurativo, entre o período de março e junho de 2014. As informações foram organizadas com o recurso do programa NVivo 10 e submetidas à análise de conteúdo do tipo temática, surgiram três categorias: Checklist para a segurança do paciente: ainda um desafio, Motivos da não adesão ao checklist da Cirurgia Segura, Etapas do Checklist. Os resultados ressaltam que o checklist é de suma importância e contribui como uma barreira para prevenir possíveis erros de lateralidade do procedimento cirúrgico e de troca de paciente na sala operatória, além de assegurar a correta identificação do paciente no momento do preparo para ingressar no centro cirúrgico. Nos debates foi ressaltado que o grupo pesquisado conhece o instrumento para a realização do checklist da cirurgia segura, porém, refere ter dificuldades para o preenchimento do mesmo, principalmente devido à necessidade de agilizar o processo e encaminhar rapidamente o paciente à sala de cirurgia. Foi percebido que existem falhas no preenchimento do protocolo da cirurgia segura, em algumas situações o instrumento é preenchido antes de iniciar a cirurgia ou após o término da mesma. É fundamental envolver e comprometer as equipes médicas para a aplicação do checklist da cirurgia segura, além de (re) orientar e empoderar as equipes de enfermagem, a fim de seguir corretamente o protocolo da lista de verificação instituída, minimizando situações de desvalorização e ridicularização da rotina. A aplicação de maneira correta desse protocolo contribui para o reconhecimento assistencial das equipes na instituição. A natureza participativa do método de pesquisa fotográfico restaurativo oportunizou o engajamento dos profissionais do campo de estudo e possibilitou implementar muitas melhorias, a partir de sugestões e propostas dos mesmos. Outro aspecto que merece ser destacado, diz respeito ao duplo papel de pesquisador e gestor da instituição investigada, que permitiu traduzir os conhecimentos produzidos a partir do estudo em ações no cenário da prática assistencial, transformando-o em um ambiente mais seguro para o paciente. / The security concept was born with primitive man to fight daily to survive against attacks by predators. Over the years arose survival and safety parameters in almost all work activities. In the health and nursing area this theme has mobilized efforts of health organizations to avoid gaps in care processes that may cause adverse events to patients. This is an exploratory, descriptive research with a qualitative approach, in order to analyze the application of the safe surgery checklist in the operating room for patient safety. The study was conducted using the technique of focus groups and photographic research methods from the perspective of restorative ecological thinking, in the period between March and June 2014. The information was organized with the use of NVivo program 10 and subjected to analysis of thematic content, there were three categories: Checklist for patient safety: still a challenge, Reasons for non-adherence to the Safe Surgery Checklist, Steps Checklist. The results emphasize that the checklist is very important and contributes as a barrier to prevent possible errors laterality of the surgical procedure and patient exchange in the operating room, and ensure the correct identification of the patient while preparing to enter the operating room. In the discussions it was stressed that the group researched know the instrument for the achievement of the safe surgery checklist, however, concerns have trouble completing it, mainly because of the need to streamline the process and quickly refer the patient to the operating room. It was noticed that there are errors in the completion of the safe surgery protocol, in some situations the instrument is filled before starting surgery or after the same. It is essential to involve and engage the medical teams to the application of the safe surgery checklist, and (re) direct and empower the nursing staff in order to properly follow the established checklist protocol, minimizing devaluation situations and ridicule of routine. The application correctly this protocol contributes to the recognition of care teams in the institution. The participatory nature of the photographic restorative search method provided an opportunity to engage the professional field of study and made it possible to implement many improvements from suggestions and proposals from them. Another aspect that deserves to be highlighted concerns the dual role of researcher and manager of the investigated institution, which translated the knowledge produced from the study into shares in the care practice setting, turning it into a safer environment for the patient. / El concepto de seguridad nació con el hombre primitivo que luchar a diario para sobrevivir contra los ataques de los depredadores. Con los años surgieron parámetros de supervivencia y seguridad en casi todas las actividades de trabajo. En el área de la salud y de enfermería este tema ha movilizado esfuerzos de las organizaciones de salud para evitar lagunas en los procesos de atención que pueden causar efectos adversos a los pacientes. Se trata de una investigación exploratoria, descriptiva con enfoque cualitativo, con el fin de analizar la aplicación de la lista de verificación de la seguridad quirúrgica en el quirófano para la seguridad del paciente. El estudio se realizó mediante la técnica de grupos focales y los métodos de investigación fotográficos desde la perspectiva del pensamiento ecológico restaurativa, en el período comprendido entre marzo y junio de 2014. La información se organizó con el uso del programa NVivo 10 y se sometió a análisis de contenido temático, había tres categorías: Lista de verificación para la seguridad del paciente: sigue siendo un reto, Razones para la no adhesión a la Lista de verificación de cirugía segura, Pasos Lista de verificación. Los resultados ponen de manifiesto que la lista es muy importante y contribuye como una barrera para evitar posibles errores de lateralidad del procedimiento y paciente intercambio quirúrgica en el quirófano, y garantizar la correcta identificación del paciente mientras se preparan para entrar en la sala de operaciones. En los debates se destacó que el grupo investigado conocen el instrumento para el logro de la lista de verificación cirugía segura, sin embargo, las preocupaciones tienen problemas para completarla, principalmente a causa de la necesidad de racionalizar el proceso y rápidamente derivar al paciente a la sala de operaciones. Se observó que hay errores en la finalización del protocolo de cirugía segura, en algunas situaciones el instrumento se llena antes de comenzar la cirugía o después de la misma. Es esencial involucrar y comprometer a los equipos médicos a la aplicación de la lista de verificación de la seguridad quirúrgica y (re) dirigir y capacitar al personal de enfermería con el fin de seguir correctamente el protocolo de lista de control establecido, minimizando situaciones de devaluación y el ridículo de rutina. La aplicación correcta de este protocolo contribuye al reconocimiento de los equipos de atención en la institución. El carácter participativo del método de búsqueda restaurador fotográfico proporcionado una oportunidad para entablar el campo profesional de estudio e hizo posible la implementación de muchas mejoras de sugerencias y propuestas de ellos. Otro aspecto que merece ser destacado se refiere a la doble función de investigador y director de la institución investigada, que tradujo el conocimiento producido a partir del estudio en acciones en el ámbito de la práctica de atención, convirtiéndola en un entorno más seguro para el paciente.