Principles of clinical management: connecting management, healthcare and education in health

Roberto de Queiroz Padilha Romeu Gomes Valéria Vernaschi Lima Everton Soeiro José Maurício de Oliveira Laura Maria Cesar Schiesari Silvio Fernandes da Silva Marilda Siriani de Oliveira About the authors

Abstract

This paper aims at proposing validated principles to underpin clinical management as a means to transform healthcare for integrated healthcare systems. The starting point was the conception of clinical management based on structuring elements that do not separate management, care and education. The authors’ proposal was submitted to specialists so that a consensus could be reached. At the end of the process, the following principles of clinical management were presented: (1) Focus on health needs and comprehensive care, (2) Quality and safety in healthcare, (3) Articulation and legitimation of different health practices and types of knowledge to face health problems, (4) Power sharing and co-accountability among managers, health professionals and citizens in healthcare production; (5) Education of people and organizations; (6) Focus on outcomes that add value to health and life; (7) Transparency and accountability regarding collective interests. It is concluded that the principles of clinical management express connections that shed new light on management, healthcare, and education in integrated healthcare systems, requiring critical awareness in relation to the simultaneity of “permanence” and change in practices.

Clinical management; Delivery of healthcare; Health systems; Health management

Introduction

The creation of integrated health systems gained strength in the second half of the 20th century, with the emergence of the National Health Service - NHS11. National Health Service. [acessado 2016 Abr 23]. Disponível em: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx
http://www.nhs.uk/NHSEngland/thenhs/abou...
. The Brazilian National Health System (SUS) was influenced by this model, whose most relevant dimensions involved changes in financing, coverage, access to services, and in the comprehensiveness of care. In this field, one of the initiatives with a systemic scope is that of clinical governance, which emerged in the 1990s in the sphere of the NHS. Focusing on quality, it was defined as a system through which health organizations commit to continually improving their services and to maintaining high standards of care, thus creating an adequate environment for clinical excellence22. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998; 317(7150):61-65..

Clinical governance has influenced other health systems to define and implement policies and guidelines aiming to improve the quality of the clinic, tackling, among other factors, variability in care provision. The authors who take the NHS as reference propose seven pillars for clinical governance: clinical effectiveness, clinical audit, risk management, use of information, education and training, people management, and patient/public involvement22. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998; 317(7150):61-65.. In Spain, this dimension of care is called Gestión Clínica and its main objective is to ensure the provision of comprehensive care, coordinated and centered on the patient33. Consorci Hospitalari de Catalunya (CHC). Consultoria i Gestión. Gestión Clinica: Conceptos, herramientas y operativizacion. Apresentação no Simpósio Internacional de Cirurgia Segura e Gestão da Clínica. 11 de Noviembre de 2008.. The key concepts are quality and effectiveness, common objectives for all the agents involved, progressive decentralization, autonomy, and co-accountability in the obtention of outcomes33. Consorci Hospitalari de Catalunya (CHC). Consultoria i Gestión. Gestión Clinica: Conceptos, herramientas y operativizacion. Apresentação no Simpósio Internacional de Cirurgia Segura e Gestão da Clínica. 11 de Noviembre de 2008.,44. Temes JLM, Parra B. Gestión Clínica. Madrid: Mc Graw Hill Interamericana; 2000.. In Australia, publications about clinical governance focus on four dimensions: clinical performance and assessment; professional development; risk and safety; values and involvement of patients/users22. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998; 317(7150):61-65..

In a literature review about this theme55. Gomes R, Lima VV, Oliveira JM, Schiesari LMC, Soeiro E, Damázio LF, Petta HL, Oliveira MS, Silva FS, Sampaio SF, Padilha RQ, Machado JLM, Caleman G. A Polissemia da Gestão da Clínica: uma revisão de literatura. Cien Saude Colet 2005; 20(8):241-249., the authors focused on the period from 2009 to 2013 and found that the articles they collected revealed the permanence of the seven pillars of clinical governance, even though there was polysemy concerning their translation, and discussions about the operational plane, with less emphasis on the meso and macro levels of health management. According to the authors of this review, tensions between standardization-singularization and control-autonomy were not sufficiently problematized, considering the complexity of health work.

In Brazil, although tensions related to the management of health work have been published66. Merhy EE. Em Busca do Tempo Perdido: a micropolítica do trabalho vivo em saúde. In: Merhy EE, Onocko R, organizadores. Agir em Saúde: um desafio para o público. São Paulo: Hucitec; 1997. p. 71-112.

7. Cecilio LCO. Autonomia versus controle dos trabalhadores: a gestão do poder no hospital. Cien Saude Colet 1999; 4(2):315-329.
-88. Campos GWS. A reforma da reforma. São Paulo: Hucitec; 1992. since the 1980s, the term clinical management was employed by Mendes99. Mendes EV. Os grandes dilemas do SUS: tomo II. Salvador: Casa da Qualidade; 2001.in 2001. This author used elements of clinical governance and managed care to define it as a set of micromanagement technologies that, based on clinical guidelines, aims to provide:

“high-quality, people-centered, effective healthcare structured on scientific evidence; healthcare that is safe, not causing damages to patients and professionals, efficient, provided with optimal costs, opportune, provided on the right time, equitable, in order to reduce unfair inequalities, and offered in a humanized way”1010. Mendes EV. As redes de atenção à saúde. Brasília: Organização Pan-Americana da Saúde; 2011..

If we consider that health organizations provide services through the translation of their professionals’ knowledge into clinical decisions, these professionals’ degree of autonomy and control in the decision-making process is one of the most sensitive elements, both in clinical governance and in managed care1111. Mintzberg H. Criando Organizações Eficazes: estrutura em cinco configurações. São Paulo: Atlas; 2003.. In this context, the lack of recognition or problematization of tensions produced by the control performed by management over the clinic tends to introduce technologies in a verticalized, little contextualized or little singularized way1212. Campos GWS, Amaral MA. A clínica ampliada e compartilhada, a gestão democrática e redes de atenção como referenciais teórico-operacionais para a reforma do hospital. Cien Saude Colet 2007; 12(4):849-859.,1313. Cecilio LCO. Autonomia versus controle dos trabalhadores: a gestão do poder no hospital. Cien Saude Colet 1999; 4(2):315-329..

To face this challenge, the clinical management approach we defend recognizes the importance of subjects involved in relationships established in comprehensive care and in the consequent learning processes, conceived within the healthcare-management-education trinomial. Therefore, health managers and professionals should build common objectives, for which they share knowledge and professional effort, and in which they are equally involved. In this context, critical awareness and commitment are vectors in the construction of a metapoint of view1414. Morin E. O método 3: o conhecimento do conhecimento. Porto Alegre: Sulina; 2008..

Thus, clinical management - the object of our study - aims at the production of comprehensive care with quality and safety, targeted at people’s and populations’ health needs, by means of the transformation of care, management and education practices.

Based on this definition, principles that characterize a problematizing approach and go beyond the initial marks attributed to the expression “clinical management” in Brazil were identified. The objective of this article is to present the validation of these principles.

Methodology

In this study - which is based on opinions -, we started from our experience and then asked specialists in the matter to validate it, thus amplifying the forum of opinions in order to reach a consensus. To do this, we adapted the consensus conference technique proposed by Souza et al.1515. Souza LEPF, Vieira-da-Silva LM, Hartz ZM. A Conferência de consenso sobre a imagem-objetivo da descentralização da atenção à saúde no Brasil. Hartz ZMA, Silva LMV, organizadores. Avaliação em saúde: dos modelos teóricos à prática na avaliação de programas e sistemas de saúde. Salvador, Rio de Janeiro: EDUFBA, Fiocruz; 2005. p. 65-102..

Initially, we revisited our practice of qualifying health professionals in clinical management and developing comprehensive care projects with quality and safety in SUS. This practice revealed challenges concerning the articulation of the three “structuring” axes (healthcare model, health management model and conception of education in health) and the production of critical awareness to singularize quality improvement processes in health services1616. Soeiro E, Schiesari L, Padilha RQ, Lima VV, Oliveira MS, Oliveira JM, Silva SF, Gomes R. Especialização em gestão da clínica nas regiões de saúde: caderno do curso 2015/2016. São Paulo: Instituto Sírio-Libanês de Ensino e Pesquisa, Ministério da Saúde; 2015.. To face these challenges, we created a table of principles with descriptors. The principles were understood as bases or foundations that underpin a clinical management targeted at the transformation of practices.

Then, we selected specialists to play the role of validators. The first selection criterion was to identify authors of articles that focused on themes related, directly or indirectly, to clinical management, registered in the Scientific Electronic Library Online (SciELO), in May 2015. This library was chosen because it contains the main national publications of articles in the area of public health. In addition, we identified professionals involved with the implementation of clinical management proposals in SUS, in the sphere of the Ministry of Health. Based on these two criteria, 15 specialists were chosen. Three of them did not answer the invitation to participate in the study and five refused to participate in it.

The group of specialists was constituted of seven validators: five authors of articles about the theme and two managers. Two authors were associate editors of scientific journals. As we were not dealing exclusively with the quantitative dimension, we did not consider the loss of eight specialists a requisite for not continuing with the study.

After this stage, we sent the table of principles to the validators by electronic mail in June 2015. In this table, each principle could be scored in a scale from 0 to 10, where 0 meant no importance or exclusion and 10, maximum importance. In addition, it was possible to include remarks or suggestions.

The specialists’ scores were treated through the calculation of means and standard deviations. To better understand the obtained results, we held a face-to-face encounter in August 2015, attended by four of the seven validators. In this encounter, the scores and suggestions of exclusion or addition of principles were presented, without disclosing their authors. Each participant gave their opinion about the table and scored the principles individually again (from 0 to 10).

After this encounter, we synthesized the opinions and suggestions to recalculate the mean and standard deviation (SD) of each principle. In the new table, only principles with mean equal to or higher than seven and SD equal to or lower than two were included. We sent the new table to the seven specialists in November 2015 and used the same statistical criteria in the second validation round, which took place in December 2015.

Results

Of the ten principles presented initially to the specialists, five had standard deviation higher than 2.0; therefore, they were not validated (Table 1).

Table 1
Principles of Clinical Management (First Version).

Based on the discussion that occurred in the encounter with the specialists, a new table of principles was developed (Table 2). In this table, suggestions for exclusions and additions were incorporated and some principles that had been validated in the first round were renamed, resulting in seven principles. In the second round, the seven principles were validated.

Table 2
Principles of Clinical Management.

The first principle of Table 2 obtained an absolute consensus, with a mean of 10 and SD of 0. In the other principles, the consensus was high, as the lowest mean was 8.86 and the highest SD was 1.46.

Discussion

When we examine the validated principles of clinical management, we see that there are significant distinctions in their applicability, according to the health system modeling (Chart 1). Considering relevant elements highlighted by Mendes1010. Mendes EV. As redes de atenção à saúde. Brasília: Organização Pan-Americana da Saúde; 2011.in the characterization of fragmented systems and healthcare networks, the fragmented systems make five of the seven principles of clinical management impossible.

Chart 1
Characteristics of health systems.

Regarding integrated systems, we highlight the characteristics of the three “structuring” axes that guided the construction of the seven validated principles: (i) healthcare model; (ii) health management model; and (iii) conception of education in health.

In the first axis, the shift from disease to the health needs of subjects or social groups reorients healthcare. In this sense, the clinic is not reduced to the diagnosis and treatment of the disease as a pathological entity, with its etiological and nosological aspects. Canguilhem1717. Canguilhem G. O normal e o patológico. Rio de Janeiro: Forense Universitária; 2009.highlighted the challenge of disregarding the existence of the pathological in itself, examining it in a relationship with the individual and the society. Cecílio1818. Cecílio LCO. As Necessidades de saúde como conceito estruturante na luta pela integralidade e equidade na atenção em saúde. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ/IMS, Abrasco; 2009. p. 117-130. argues that, when we take health needs as the reference, teams of professionals and management levels are able to achieve “a good device to qualify and humanize the health services”. So that clinical management is able to operate in the logic of health needs, it cannot be limited to the biological dimension1212. Campos GWS, Amaral MA. A clínica ampliada e compartilhada, a gestão democrática e redes de atenção como referenciais teórico-operacionais para a reforma do hospital. Cien Saude Colet 2007; 12(4):849-859. nor act in isolation, as “no isolated level of the health systems has competence or all the necessary resources to meet the health needs of a population”1919. Giovanella L, Mendonça MHM, Almeida PF, Escorel S, Senna MCM, Fausto MCR, Delgado MM, Andrade CLT, Cunha MS, Martins MIC, Teixeira CP. Saúde da família: limites e possibilidades para uma abordagem integral de atenção primária à saúde no Brasil. Cien Saude Colet 2009; 14(3):783-794..

The second axis regards the management model. Paula2020. Paula APP. Administração pública brasileira entre o gerencialismo e a gestão social. RAE 2005; 45(1):36-49. draws a comparison between managerialism and social management that is, to some extent, related to this shift. To the author, the first model is aligned with the functionalist conception, without taking political processes into account. According to her, there are limits and positive points in the two models. Without reducing managerialism to the fact of merely focusing on tasks, we understand that the validated principles are linked to a democratic and participative management, requiring, according to Campos2121. Campos GWS. Cogestão e neoartesanato: elementos conceituais para pensar o trabalho em saúde combinando responsabilidade e autonomia. Cien Saude Colet 2010; 15(5):2337-2344., a combination of autonomy and responsibility, with creativity and health commitment.

Finally, the conception of education as the third axis implies the understanding that learning occurs as the result of social interaction processes, in which knowledge and practices are built in the relationship between the subject who learns and objects to be learned2222. Vygotsky LS. A formação social da mente: o desenvolvimento dos processos psicológicos superiores. São Paulo: Martins Fontes; 1998.. This conception shifts educational processes from hierarchized relationships to dialogic relationships among subjects who exchange knowledge, values, desires and interests, and, because of this, transform practices.

In addition to the shifts in the three axes, there are transversal aspects of the principles in question. One of them refers to the way of dealing with and considering the other in health work relationships. When people are considered legitimate in their singularity2323. Maturana H. Emoções e linguagem na educação e na política. Belo Horizonte: Editora UFMG; 2005., there is the construction of a metapoint of view1414. Morin E. O método 3: o conhecimento do conhecimento. Porto Alegre: Sulina; 2008. in relation to different perspectives attributed to the health-disease process. In the care model, this orientation amplifies the focus given by the professional and biomedical knowledge perspective, including the subjective and social dimensions of health production in the explanation of phenomena and in agreements on interventions, respecting patients’ interests and desires. In the management and education models, the construction of subjects’ protagonism and co-accountability requires the expansion of critical and reflective awareness and the sharing of power.

Another aspect that traverses the principles is the transformation of practices. In human societies, this occurs by means of learning. Although Polanyi2424. Polanyi K. A grande transformação: as origens da nossa época. 2a ed. Rio de janeiro: Campus; 2000. and Hobsbaum2525. Hobsbaum E. A era dos extremos: o breve século XX, 1914-1991. São Paulo: Companhia das letras; 1995.argue that the production of material wealth is the ultimate determinant of social transformations, they recognize the influence of political, cultural and educational components on these processes. According to Piketty2626. Piketty T. O capital no século XXI. Rio de Janeiro: Intrínseca; 2014., dissemination of knowledge and competence is one of the most important convergence mechanisms to improve distribution of wealth and reduce inequalities. Thus, education enables a critical reflection on the way society organizes itself, potentializing this force of convergence for transformation processes.

Just like people learn, organizations formed by people can also learn2727. Morgan G. Imagens da organização. 2a ed. São Paulo: Atlas; 2002.. An organization where power is shared can generate upward and downward movements both in the management and in the permanent education of the individuals involved. In addition, it can promote the construction of a culture of assessment, aiming to reorient health practices by means of the utilization of mistakes and successes as subsidies to improve performance.

Finally, the third transversal aspect is the production of comprehensive care. Here, comprehensiveness should be understood in a broad way. We agree with Ayres et al.2828. Ayres JRCM, Carvalho YM, Nasser MA, Saltão RM, Mendes VM. Caminhos da integralidade: adolescentes e jovens na atenção primária. Interface (Botucatu) 2012; 16(40):67-81., who consider this expression based on four axes targeted at needs, purposes, articulations and interactions. To Ayres2929. Ayres JRCM. Prefácio. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8ª ed. Rio de Janeiro: UERJ/IMS, Abrasco; 2006. p. 11-14., care and comprehensiveness are similar ideas, even though in the unreachable limit of utopia and, because of this, indispensable. Comprehensiveness of care as a principle is, to this author, what challenges us to do what and how to meet health needs.

Final remarks

The possible connections among management, healthcare and education that are configured in the sphere of clinical management can be understood in light of social contemporaneity. When we try to understand them, we make an association with aspects of Bauman’s conception3030. Bauman Z. Modernidade líquida. Rio de Janeiro: Zahar; 2001.. To this author, the relationships between individuals and institutions tend to become less frequent and lasting, as they are inserted in a period of fluidity, volatility, uncertainty and insecurity (liquid modernity) that has replaced a previous period marked by more solid references.

When we put the principles of clinical management proposed here into practice, we believe that we will experience tensions between permanence and change, as these principles translate a problematizing approach to health practices whose vector lies in critical awareness and dialogism for the production of transformational interventions. Transformations in the three structuring axes must be constructed by articulating different types of knowledge and sharing the power to decide among managers, professionals and users, aiming at comprehensive, high-quality and safe care, focusing on people’s and populations’ health needs. To be able to live with these challenges, it is important that we learn to experience simultaneity between alleged certainties and uncertainties, by means of a critical awareness open to change.

Acknowledgements

To the specialists: Adail de A. Rollo, Alzira de O. Jorge, Eleonor M. Conill, Lígia Giovanella, Luciana D. Lima, Margareth C. Portela, and Ricardo B. Ceccim.

References

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    Maturana H. Emoções e linguagem na educação e na política Belo Horizonte: Editora UFMG; 2005.
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History

  • Received
    03 July 2016
  • Reviewed
    04 Jan 2017
  • Accepted
    06 Jan 2017
  • Publication
    Dec 2018
ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil
E-mail: revscol@fiocruz.br