Espacios. Vol. 36 (Nº 24) Año 2015. Pág. 19
Bianca Soares Oliveira GONCALVES 1; Marcel Andreotti MUSSETTI
Recibido: 19/08/15 • Aprobado: 12/10/2015
To achieve the purpose of this investigation, outpatient logistic activities were identified, which led to the construction of a conceptual model addressing concepts of integrated logistics. Logistics activities were then correlated with accreditation standards. Performed a systematic literature about accreditation process e accreditation Library and Web of Science. To better characterize logistic activities, the Enterprise Knowledge Development method was used to model the outpatient logistic activities of a public teaching hospital accredited with excellence – the State Hospital of Sumaré. Fourteen logistics activities were listed and only one had no relationship with the accreditation, evidenced the relationship between logistics and accreditation. Based on the results, accreditation standards correlate to logistic activities, which comprise norms that are essential to obtain accreditation. Therefore, this study may be a guide for hospitals that seek accreditation.
Esta pesquisa tem como objetivo identificar e analisar os vínculos entre as atividades logísticas e a acreditação de um ambulatório de um hospital público de ensino, oferecendo uma contribuição para acreditação neste tipo de hospital por meio da descrição das atividades logísticas que alavancam este processo. Para atingir o objetivo da pesquisa foi realizada a metodologia de modelagem organizacional Enterprise Knowledge Development (EKD) como base descrever as atividades logísticas ambulatórias que contribuem para a acreditação, sendo esta modelagem realizada por meio de um estudo de caso no Hospital Estadual de Sumaré (um hospital público de ensino). Diante dos resultados foram identificadas normas da acreditação que se relacionam com as atividades logísticas ambulatoriais e este vinculo ocorre por meio das regras de negócio que quando utilizadas por um hospital para estruturar sua logística poderão alavancar o processo de acreditação. Pode-se concluir que o hospital que priorizar a estruturação de sua logística, com o foco na logística integrada estará preparando-se também para atender às exigências da acreditação.
The implementation of strategies to improve the quality of patient care in Healthcare Providers (HCP) is progressing. These include accreditation systems, management programs, clinical audits, strategies to ensure the patients' safety, performance indicators, and surveys to collect patient opinion. However, quality and safety issues still exist. Therefore, the debate on how to accelerate and sustain an improvement of quality has become more relevant than ever (GROENE et al, 2013).
Seeking a single strategy to improve quality, the Brazilian government, supported by other institutions, funded the National Accreditation Agency in 2001, which made accreditation the major authorized quality program managed by the Brazilian Ministry of Health. Accreditation is a voluntary, periodic, and reserved process that evaluates institutional resources and – through previously accepted standards – aims to ensure healthcare quality. The term "accreditation" means having a good reputation and being trustworthy. Therefore, accreditation must be a continuous education program, rather than a form of supervision (POMEY et al, 2004). Accreditation programs lead to the improvement of all the people involved, with the patient being the main beneficiary. Moreover, it improves patient care quality and provides opportunities for HCP to optimize their processes (JARDALI et al, 2013). According Paccione and Champagne (2008), hospital accreditation emerged as a possibility to ensure users, professionals, and the general public the safety required by health services. In other words, the implementation of medical procedures and medical assistance should be provided with promptness, expertise, and excellence. Accreditation for Public University Hospitals is not common in Brazil. A total of 128 university and teaching hospitals were accredited so far, of which 83 are public (federal, state, and municipal) (ABRAHUE). Among these public hospitals, only three (3.6%) received accreditation. Described the difficulties that public hospitals face in obtaining accreditation, because of the difficulty in acquiring sufficient funding for a long-term process (which begins with the preparation of internal processes) (SALEH et al, 2013; JAAFARIPOOYAN et al 2011). Since accreditation is a national certification procedure (i.e., it is a procedure conducted in Brazil), no other country uses this certification.
This study aims to identify and analyze the correlations between hospital logistics and accreditation in the outpatient clinic of a public teaching hospital. We show that logistic activities are identified using Integrated Logistics, which includes the flow of materials, patients, and information. This concept incorporates logistics as part of a process that manages the supply chain and is capable of planning, implementing, and controlling the direct and reverse flow, and the efficient and effective storage of goods, services, and related information, from their origin to the consumption, in order to satisfy customers' requests. Patient flow requires an integrated vision, and not one fragmented into specialties. Therefore, the improvement of patient flow is essential for an OPSS, because it increases productivity and customer satisfaction, without investing in capacity expansion. Hence, this flow should be integrated with information and materials (DRUPSTEEN et al, 2013).
Logistics, human resources, and financial management are critical for the development of healthcare activities and the operational excellence of a hospital organization. These are also crucial to understand how some outpatient logistic activities may leverage the accreditation process, the maintenance of which may facilitate the accreditation of public hospitals, which still encounter many difficulties in achieving this certification (NEIL, 2004).
This study is divided into three parts: type, approach, and design.
This exploratory studyseeks more familiarity with the problem, to answer the following question: how can logistics contribute to award the accreditation of an outpatient clinic? The purpose of this article is to identify and analyze the logistic activities of an outpatient clinic, which are essential to achieve that accreditation (GIL, 1993). This investigation was carried out using a survey on the main logistic activities that contribute to an outpatient clinic accreditation. The next step was to characterize logistics activities using a case study. To model logistics activities the EKD (Enterprise Knowledge Development) method was used. The EKD is a method based on organizational modeling, which provides a systematic and controlled way to analyze, develop, and document an organization and its components (PADUA et al, 2004). The EKD method produces a final model, which is then used by decision makers to define organizational strategies. This final model includes a series of sub-models that are interrelated to form its structure. Each of these models represents different aspects of the organization. The model of objectives describes organization ideas in addition to outlining what the organization and its employees would like to achieve or to avoid and the time frame in which this should occur. The Business Rules Model is used to define and maintain the strict business rules previously established. The Concepts Model is used exclusively to define phenomena and events related to other models. The Business Process Model is used to define the processes of the organization and how they interrelate to manage information, people, and materials. This model considers that information and materials should be consumed during the process, whereas an output of information, people, and materials should be produced. The Actors and Resources Model is used to describe the correlation between different actors and resources.
The method of this investigation is qualitative, as an approach that presents the natural environment as a direct source of data, and the researcher as its main tool (a direct contact with the hospital was established). The data collected are descriptive (the interviews allowed the construction of a model that describes the logistical activities of the hospital), and the major concern is the process and not the product (the logistics processes were described in detail) (BOGDAN AND BIKLEN, 1994).
The study design is a case study, defined as the way to perform empirical social research that investigates a current phenomenon within a real life context. Moreover, it should focus on clarifying the boundaries between the phenomenon and its context and provide multiple sources of evidence that may be used (YIN, 2001). To describe and characterize the logistics activities that may leverage the accreditation of an outpatient clinic, the State Hospital of Sumaré (the only hospital to be accredited with excellence), was chosen for this study. Logistics activities were modeled with EKD. The interviews in this study are semi-structured, that is, they cover a specific number of topics, which were used to identify logistics activities essential for the accreditation. This enabled us to collect information, experiences, perceptions, and interpretations from the director of the outpatient clinic (SHAH AND CORLEY, 2006). To collect data, the Sumaré State Hospital was visited thrice. During the first visit, information was collected about each logistical activity previously surveyed and identified as being essential for accreditation; the nurse responsible for the clinic was interviewed. In the first survey, the interviews are semi-structured and are used to identify the logistical activities identified as essential for accreditation; collecting the information, experiences, perceptions, and interpretations of the person responsible for the clinic was still necessary (Shah; Corley, 2006). The focus of the second visit was the main rules of procedures. The third visit to the hospital was performed to validate the models of objectives, rules, procedures, actors, and resources that were developed, as well as to conduct the final review of the modeling.
However, describing the logistical activities based on outpatient hospital experience does not mean that its step-by-step process, described later, cannot be used by other hospitals, because the surveyed logistical activities are present in clinics in general. To model the logistical activities, the EKD (Enterprise Knowledge Development) methodology shall be used.
The EKD methodology provides a systematic and controlled technique to analyze, develop, and document an organization and its components, using an organizational modeling approach (Rolland; Nurcan; Grosz, 2000). The proposal to use EKD is to provide a clear and unambiguous description of how the logistical activities of the outpatient clinic of the Sumaré State Hospital work; therefore, in this case, a field trip was utilized to model those activities. The EKD methodology can be used to develop a final model that is used by decision makers for strategic definitions in the organization. This final model has a number of sub-models that interrelate, composing its structure. Each of these models represents an aspect of the organization. Additionally, EKD provides an integrated view of the flow of people, material, and information, which is the focus of this research, because there is a gap in the bibliography on hospital logistics that does not take these integrated flows into consideration.
To characterize key logistics activities that contribute to accreditation, a case study was carried out in the State Hospital of Sumaré, which was accredited with Level 3, a level of excellence, using the EKD method. In the State Hospital of Sumaré (SHS), directed by Dr. Leandro Francheschinni, the hospital assistance is provided by the Unified Health System (UHS - a set of actions and healthcare services provided by agencies and public institutions) to the four basic clinics (clinical medicine, general surgery, pediatrics, and gynecoobstetrics). Thirty-seven specialties with a high level of qualification are offered, along with the capacity for 1,500 monthly admissions. This is a state government hospital, which is administered by Unicamp and maintained with the financial support of UHS. Access to this healthcare service is coordinated by municipalities of the area covered by SHS and, in particular, by physicians practicing in these cities, who schedule hospital assistance through SHS services. The identification, characterization, and description of key logistics activities essential for an outpatient clinic to achieve accreditation are crucial to ensure that this study serves as a guiding instrument. Therefore, this study aims to describe how logistic activities in an accredited hospital should guide a health-care organization towards the accreditation of its outpatient facilities. Figure 1 shows the model of hospital outpatient logistics processes mentioned above.
Figure 1 Model processes and actors
The figure illustrates the Processes Model together with the and Actors Model. In the Process model, each action is linked to an actor, that is, for each action the name of who executes it appears. The modeled processes are logistics processes correlated with the flow of patients, information, and materials, by the concept of integrated logistics. The outpatient logistics of this hospital are composed of seven processes, in which four occur directly within the outpatient clinic (Process 1 - manage admission, Process 2 - attend the patient, Process 3 - attend the patient, and Process 4 - reschedule the patient). These main processes are represented by rectangles with solid lines. The remaining 3 processes do not occur directly within the outpatient clinic, are therefore named as support processes, and are represented in the figure by rectangles with broken lines, for ease of identification. Support processes are not more or less essential than main processes, but they do not occur frequently in the outpatient clinic. Support Process 1 – manage the offer: a nurse (in the nursing area) with access to a computer carries out the process, whichdoes not directly occur in the outpatient clinic. Process 2 – schedule the patient: this process takes place in the Public Health Center, as this hospital did not have an "open door" policy, or attend any patient who was not previously scheduled in the center. Support Process 3 – charts are primarily processed by the SMAS (Service of Medical Support and Statistics). The Processes Model starts when the patient goes to the Public Health Center (PHC) of his city (Americana, Hortolândia, Monte Mor, Nova Odessa, Santa Bárbara D'Oeste, and Sumaré).Through medical referral, the patient is then directed to the State Hospital of Sumaré, whenever secondary medical assistance is required. The schedule is processed by the hospital system and the list of scheduled patients pass through accordingly. On the scheduled day, the patient arrives at the hospital, received by receptionists and attended to by the clinical staff. Subsequently, if necessary, the patient could be rescheduled to return to the hospital or leave. Note that the flow of materials is indicated by blue arrows, whereas the flow of charts by red arrows.
Figure 2 shows the Rules Model of outpatient logistics for the State Hospital of Sumaré. First, the model of the main rules is presented with the aims and main processes. Process 3 includes the sub-process named "Office materials control." Therefore, the rules concerning materials indirectly correlate with the process "Attend to the patient."
Figure 2 Model of main processes, aims, and standards
Support processes and rules are shown in Figure 3.
Figure 3 Model of support process, aims and standards
The Figure 4 establishes the correlation between modeling, theoretical model, and standards for accreditation. Each activity and its respective standards were correlated with one or more processes and rules described in the modeling. The scheduling activity correlates with Process 1 - manage healthcare attendance, Support Process 1 - manage the offer, and Support Process 2 - schedule the patient. In this activity, the standard for the accreditation of "managing the flow and the service demands" correlates with the following rules:
1.1: Problems regarding the patient care service should be solved as soon as possible.
1.3: It is necessary to constantly check the progress of the patient care.
A1.1: Vacancies available in CROSS should correspond to the number of monthly vacancies that are established by the specialty.
A1.2: It is necessary to revise the number of patients attended to per month, according to the attendance report of the previous month, and the specialties schedule for the following month.
A1.3: The number of patients attended should change according to the resources (human, materials, equipment, and financial).
A1.4: The number of patients attended to per month should be in accordance with the schedule available for the specialty.
A2.1: Unfilled vacancies until the 20th of each month will be at the disposal of any municipalities that can fill them in order of arrival.
A2.2: Secondary, and possibly tertiary, care should be offered to the patients.
A 2.3: Consultations should be scheduled when the outpatient clinic is opened, from Monday to Friday, 7:00 am to 7:00 pm.
A2.5: The number of vacancies available in each specialty should be assessed in each municipality.
The standard "control and schedule" includes the frequency, duration, distribution, and performance of medical consultations. Within the scheduling activity, this norm correlates with "the scheduling control system should contain the following information: frequency, duration, distribution, performance of medical consultations, and request management."
Therefore, the schedule of logistics activity described in the theoretical model may leverage the accreditation, because there are accreditation standards that correlate with this activity, and become the organizational rules necessary for accreditation, as illustrated in Figure 4. The same process occurs with other logistics activities. However, some standards were not associated with the models rules, whereas others, such as "administrative controls for items under the legal surveillance system," included in the "Material Handling," activity did not correlate with any other rule, because it is a legal requirement. In other words, this standard is legally regulated, and therefore does not need an institutional rule because the law is fulfilled. Another standard to which this explanation applies is "legal technical responsibility." Other standards are not applied (ANA) to the case modeled in this thesis, for instance the "process via which identification and selection are accomplished and systematized, respectively, according to the level of complexity and specialization of the organization." This standard is related to the screening process, and does not exist in the outpatient clinic of the hospital modeled. This is because this hospital has a "closed-door" policy, meaning that it only attends to scheduled patients. This means that all the scheduled patients are attended to without screening. The same process is applied to the standard "patient flow in the emergency department" ANA, for the same reason.
Logistic activities involving the dispensing and return of drugs do not correlate with any other standards, and are not considered essential for the accreditation process. Finally, as illustrated in Figure 4, it is known that the logistics activity "home care" correlates to a standard that was not described for the case modeled here, as this process is not provided in this hospital.
Figure 4 Relationship between logistics activities , rules and accreditation standards
Therefore, there is a correlation between accreditation and logistic activities. Logistics activities could leverage the accreditation when the norms related to such activities become rules of the organization processes.
Over time, organizations have needed to adapt themselves to the requirements of a globalized and dynamic market. The requirements of this adaptation included standards of efficiency and effectiveness, resource optimization, profitability, and quality, which also apply to health-related organizations. This leads an OPSS to apply for an accreditation program, which ranks institutions by quality levels and promotes the learning of values given to reality in face of a reference or standard. However, accreditation for public teaching hospitals is not a reality, as only three of these accreditations have been awarded so far in Brazil. It is therefore necessary to develop tools that facilitate the accreditation of these.
Considering this, we wanted to address the following question: how may integrated logistics contribute to achieving accreditation? The answer to this question was found in the creation of a correlation between accreditation and logistics activities. For this, we developed a case study in which logistics activities were modeled, to better characterize them. The results showed that some standards referring to logistics processes correlated to those necessary to obtain accreditation, thus suggesting they may leverage this process. The contributions of outpatient logistic activities for the accreditation of a public teaching hospital were identified and analyzed. It is important to emphasize that the aim of the model is to recommend standards and practices, and not to give instruction on implementing them.
During the study, some limitations were identified. References about hospital logistics in the literature consider logistics as an integrated process, and not limited to materials management. This allows the study to contribute to the current knowledge by showing that outpatient logistics activities may address the concept of integrated logistics.
The importance of this investigation for the accreditation of public teaching hospitals relied on the identification of standards for accreditation, which are correlated to the logistic activities that were subsequently modeled. The standards of the outpatient environment that, when established, may leverage the accreditation, have been analyzed. The vision and systematization of the outpatient clinic achieved by the EKD method may also contribute to the accreditation, as the modeling allows analyzing the flow of patients, information, and materials with integrated logistics. The models also lead to present actors, rules, and processes. Therefore, overall, the novelty of this investigation relies on the absence in the literature of studies that illustrate concepts of integrated logistics applied to an outpatient environment and interface of accreditation.
This research suggests that future studies should be performed as proposed hereby and in an environment other than outpatient, such as in a hospital. Finally, further investigations may identify procedures, techniques, and tools that would facilitate public teaching hospitals to obtain their accreditation.
This research shows that integrated logistics can contribute to accreditation, and that logistical activities that may leverage this certification have been described by the EKD organizational modeling methodology.
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