Publications IPH Magazine IPH Magazine 13th: Annals The experience of the State Hospital Sumaré / Unicamp in management by care

The State Hospital Sumaré (HES), which opened in September/2000, is an institution that belongs to the State of São Paulo and is administered by the University of Campinas (Unicamp) through the Foundation for Development of Unicamp (Funcamp). The management contract between the State and the University establishes production and quality targets that are linked to the transfer of the budget defined in this contract. Due to this feature, the hospital sought to implement contemporary management models to ensure not only the fulfillment of these goals, but also to meet its mission which includes, among its main points, be recognized as a public institution of reference in quality management.

This continuous search for quality led to the adherence to the certification process of the National Accreditation Organization (ONA) in 2001. The following year, the hospital was certified as level 1 and reached the level of Accreditation with Excellence, maximum in only 5 years. All the ONA certification process was essential to establish the quality of management of foundations and training of institutional culture. The path to the methodology certification by the Canada Accreditation was a natural process, mainly due to the need for continuous efforts to improve processes that, in turn, stems from the efforts to implement the health care quality management.

The methodology certification by the Canada Accreditation was achieved in 2012. The process for implementation of this quality management model was essential for the consolidation of the care lines. The care line for management began incipient in 2007 through the implementation of the first institutional protocols. The guidelines established by the Canada Accreditation formatted the working model for the care lines and allowed the expansion and consolidation of its shares.

The hospital care lines were defined based on their epidemiological profile. Three lines have been set: mother and child, critically ill and surgical patients. For each row, a management group was formed, named 'team', which was formed by professionals from different areas of knowledge, health professionals or not, of various hierarchical levels. In each group it was possible to find doctors, nurses, administrators, engineers, physiotherapists, pharmacists, administrative assistants, among others. Each team was given the task of reviewing all flows and processes related to the care of patients seen in the type of care, and to propose and implement corrective actions to achieve optimal flows and processes. The activities were coordinated by a team leader and there was no hierarchical level within the group; Furthermore, the hierarchical relationships that existed off the team, did not apply in group activities (For an example, a medical coordinator did not have "more authority" than other team member).

This working model allowed faster identification and troubleshooting, basically because it led to the sharing of responsibilities and decentralization of decisions. Sharing responsibilities came with the multidisciplinary activities of assistance teams in assessing "problems" and in proposing "solutions" for a very simple motto: if you find a problem, it is yours. This approach stemmed decentralizing decisions. However, the latter depends on the institutional maturity, particularly concerning high-level management.

In addition to the process management related to the line, each team inherited the management of institutional protocols in their area and also had to develop new care protocols with the responsibility of promoting multidisciplinary actions.

What are the results? As an example, I cite some of which were obtained by the surgical patient team.

The initial evaluation of the flow of patients referred for elective surgery identified several points that could be improved, both in scheduling flow of new cases and returns. They also worked in management routines to reduce the waiting time for surgical procedure from the date of the first consultation (new case consultation). Corrective measures were implemented over 18 months and reached the following results: [1] the average time of the internal queue for elective surgery has been reduced from 6 months to 2 months; [2] reduction in the number of return visits between the first consultation and surgery; in the end, it was possible to achieve the annual surgical target by reducing the number of appointments by 9,000.

The surgical team took over the management of the institutional protocol of hip fracture in the elderly and identified, based on the epidemiological profile, the need to prepare two more protocols: cholecystectomy and hernia repair. These three protocols were process indicators and results that have not changed for the actions that led to the results described in the preceding paragraph. These indicators were related to the time between admission and the procedure and the time between the rise in the operating room and hospital discharge. The discussion to find a solution to achieve the goals of these times led to the following "diagnostics": [1] would only be possible to reach them by creating a routine for admitting the patient on the same day of surgery (secondary benefit: reducing the length of stay and increased availability of bed); [2] the outpatient surgery center, located on the ground floor, and three operating rooms, had idle time; [3] would be feasible, considering the building structure, to carry out a refurbishment of the central operating room, located on the first floor, to transfer the outpatient surgery for this sector and create an area for admission on the same day of patients who require hospitalization in the post operatively; [4] the previous item would allow to free teh outpatient surgical center for a new assistance project.

These points were presented to the hospital superintendent who authorized the project. The reform of the surgical center lasted about 6 months, cost about R$ 90,000.00 and increased the number of rooms from 6 to 8. The outpatient surgeries were directed to this new structure and allowed to optimize the medical and nursing staff, as all operations were centralized in one location. There was no reduction of the surgical production, even during the period of refurbishment, and the monthly cost of the surgical areas was reduced by approximately R$ 45,000.00.

And what happened to the area of the former outpatient surgery center? After two years, it was renovated for the implementation of an ophthalmologic center with two offices and three operating rooms. This new unit will perform about 1,350 cataract surgeries and 140 vitrectomies, and other procedures (Such as, glaucoma, plastics) in the first year of operation, and the forecast is to double the number of procedures in the second year. That is, we have to create the 'Ophthalmologic patient team'!

Maurício Wesley Perroud Júnior