Rev. Enferm. UFSM - REUFSM
Santa Maria, RS, v. 10, e95, p. 1-18, 2020
DOI: 10.5902/2179769243697
ISSN 2179-7692
Submission: 22/04/2020 Approved: 07/08/2020 Publication: 20/11/2020
Original Article
Perceptions of the managers of a university hospital about quality in health
Percepções de gestores de um hospital universitário sobre a qualidade em saúde
Percepciones de los gerentes de un hospital universitario sobre la calidad de la salud
Sâmia Jamylle Santos de AzevedoI
Larissa Kelly Silva de MouraII
Camila Matias NascimentoIII
Theo Duarte da CostaIV
Pétala Tuani Candido de Oliveira SalvadorV
I Nurse. Technologist in Hospital Management. Specialist in Health Systems Auditing. Universidade Federal do Rio Grande do Norte. Natal, RN, Brazil. E-mail: samiajamylle@hotmail.com ORCID: https://orcid.org/0000-0002-7178-7379
II Technologist in Hospital Management. Specialist in Health Auditing. Universidade Federal do Rio Grande do Norte. Natal, RN, Brazil. E-mail: larissaksm95@gmail.com ORCID: https://orcid.org/0000-0001-6527-9952
III Technologist in Hospital Management. Specialist in Health Auditing. Universidade Federal do Rio Grande do Norte. Natal, RN, Brazil. E-mail: camila_kemili@hotmail.com ORCID: https://orcid.org/0000-0003-0516-9895
IV Nurse. Phd in Nursing. Universidade Federal do Rio Grande do Norte. Natal, RN, Brazil. E-mail: theodcj@gmail.com ORCID: https://orcid.org/0000-0002-9355-8382
V Nurse. Phd in Nursing. Universidade Federal do Rio Grande do Norte. Natal, RN, Brazil. E-mail: petalatuani@hotmail.com ORCID: https://orcid.org/0000-0002-3208-6270
Abstract: Objective: to describe the perceptions of managers of a university hospital about quality in health. Method: this is a descriptive study, with a qualitative approach, carried out in a university hospital in Northeast Brazil. The study population was composed of 60 managers. Data were collected between 2017 and 2018, based on a semi-structured interview. Lexicographic textual analysis was performed with the support of the IRaMuTeQ software. Results: 593 text segments were analyzed and classified in the following categories: "Influence of the management model", "Quality management tools", "Conceptions of quality in health" and "Health promotion actions". The managers understood that the management model adopted influences care, and, consequently, its quality. Conclusion: it was found that managers related quality to the problem-solving service provided to users, as well as to a good relationship between professionals and the consequent improvement in the work process.
Descriptors: Quality of Health Care; Quality Management; Health Management; Hospitals; Health Manager
Resumo: Objetivo: descrever as percepções de gestores de um hospital universitário sobre a qualidade em saúde. Método: trata-se de estudo do tipo descritivo, com abordagem qualitativa, realizado em hospital universitário do Nordeste do Brasil. A população de estudo foi composta por 60 gestores. Os dados foram coletados entre 2017 e 2018, a partir de entrevista semiestruturada. Realizou-se análise textual lexicográfica com suporte do software IRaMuTeQ. Resultados: foram analisados 593 segmentos de texto com elucidação das classes: “Influência do modelo de gestão”, “Ferramentas de gestão da qualidade”, “Concepções de qualidade em saúde” e “Ações de promoção em saúde”. Os gestores compreendiam que o modelo de gestão adotado influencia na assistência e, consequentemente, na qualidade do atendimento. Conclusão: verificou-se que os gestores relacionaram a qualidade à resolutividade do atendimento aos usuários, bem como a um bom relacionamento entre profissionais e à consequente melhoria no processo de trabalho.
Descritores: Qualidade da Assistência à Saúde; Gestão da Qualidade; Gestão em Saúde; Hospitais; Gestor de Saúde
Resumen: Objetivo: describir las percepciones de los gerentes de un hospital universitario sobre la calidad de la salud. Método: estudio descriptivo, con enfoque cualitativo, realizado en un hospital universitario en el noreste de Brasil. La población del estudio consistió en 60 gerentes. Los datos se recopilaron entre 2017 y 2018, a partir de entrevistas semiestructuradas. El análisis textual lexicográfico se realizó con el apoyo del software IRaMuTeQ. Resultados: se analizaron 593 segmentos de texto con las clases: "Influencia del modelo de gestión", "Herramientas de gestión de calidad", "Concepciones de calidad en salud" y "Acciones de promoción de la salud". Los gerentes entendieron que el modelo de gestión adoptado influye en la atención y, en consecuencia, en la calidad de la atención. Conclusión: se encontró que los gerentes relacionan la calidad con la capacidad de resolución de problemas de atención a los usuarios, así como con una buena relación entre los profesionales y la consiguiente mejora en el proceso de trabajo.
Descriptores: Calidad de la Atención de Salud; Gestión de la Calidad; Gestión en Salud; Hospitales; Gestor de Salud
Introduction
Quality is an emerging theme that has been widely discussed within the scope of health organizations. In the context of a demand for greater productivity, workers and organizations need to dedicate themselves to the maximum in the search for a good and quality service. Considering this, the mobilization of health services is taken into account, bringing up the concept of Quality Management as a way of managing an institution, through the participation of employees, in order to satisfy the client and benefit everyone in the organization.¹
The quality policy must be written, and in it, the health institution commits itself to provide care based on the needs of customers, aiming for continuous improvement in processes and products. To this end, employees must be trained to perform their duties in a manner that contemplates the objectives of the policy.²
In health services, the importance of this policy for management is observed, since it acts as a managerial methodology, and as a guide for health planning that includes evaluation and the search for quality. This may reflect on the assistance offered to the client.3 It is emphasized, therefore, that, to achieve quality, it is necessary to manage it. Furthermore, it is essential that the manager gets involved in this process.
From this perspective, it is important to emphasize that quality is multifactorial, involves technical and human dimensions and needs to be continuously evaluated. It is noteworthy that the evaluation of quality in health must cover elements of the structure, the process, and the result. The structure corresponds to the characteristics of health care, regarding objectives, physical, human, material, and financial resources.4
The process comprises the activities carried out between professionals and clients. The results correspond to the product of the assistance offered, and thus consider the satisfaction of the individuals served.4 Thus, in the process of achieving quality and establishing high-quality management, the manager is an essential figure.
As a result, the initiatives for the promotion of quality in health care worldwide are growing every day, involving from the top management of organizations to their employees. Therefore, it is important to know the perceptions and experiences of managers about this theme, because it is understood that thinking about quality as a basic element of health management is a fundamental concept for the improvement of health care.2
In addition, researchers elucidate the essential role of the health manager in the consolidation of quality policies in health services, 1-3 and it is essential to investigate the alignment of the conception of these subjects with the theme. In the midst of this discussion, the following research questions were established: How do the managers of a university hospital conceive quality in health? How do these professionals work in their institutions? Thus, the objective was to describe the perceptions of managers of a university hospital about quality in health.
Method
This is a descriptive study, with a qualitative approach. The research was carried out at a university hospital located in Natal, Rio Grande do Norte, Brazil. The administrative structure of this hospital is formed by an executive board composed of the Superintendency and three management offices: Health Care Management, Teaching and Research Management, and Administrative Management.
The study population consisted of hospital managers, both senior and middle management, totaling 73 people. It was established as an inclusion criterion: to be manager of the health unit for at least six months, a time considered to be adequate for insertion in the service's daily routine. The professionals on work leave were excluded from the study, and those with whom it was not possible to schedule an interview after three attempts, in person or via telephone, depending on the sector, did not participate either.
The 73 managers were invited verbally, in person or via telephone, to participate in the study. However, 13 managers were not interviewed due to the incompatibility of their schedules — that is, after three attempts, it was not possible to schedule the interview. Thus, the study population included 60 participants.
Data were collected between the months of November 2017 and April 2018, using a semi-structured interview, at a place and time previously agreed with the manager. The interviews were carried out by a previously trained data collector. Two research instruments were used: 1) characterization of the participant, with the collection of sociodemographic and professional data; and 2) a guide for conducting the interview, composed of two open questions - a) What is health quality for you? b) Do you use quality management strategies and tools in your work? If so, which ones? The audio of the interviews was recorded, which was allowed by the research participants. The interviews lasted for an average of 20 minutes.
The data resulting from the interviews were transcribed and submitted to lexicographic textual analysis, with the aid of the Interface R software by Multidimensionnelles de Textes et de Questionneires (IRAMUTEQ). For this purpose, the Descending Hierarchical Classification (DHC) was used, which enabled the identification of the frequency of each word and its connection with the others, in addition to assisting in the analysis of the textual corpus.
CHD is a method of analysis in which texts (the interviews by each manager) are analyzed in a lexicographic way. The classes are obtained from the grouping of text segments that, at the same time, present vocabulary similar to each other, and vocabulary different from the segments of the other classes.5 Thus, the classes represent categories of analysis with lexical vocabulary coherent with each other, representing, therefore, units of meaning of the perception of the research participants.
It is noteworthy that the study followed the ethical and legal principles that govern scientific research with human beings, which is recommended by Resolutions 466/2012, 510/2016 and 580/2018, of the Ministry of Health, preserving the voluntary nature of the participation and the anonymity of the participants. The term “manager” was used followed by a number indicating the order in which the interviews were carried out. The research was submitted for ethical review by the Ethics Committee of the proposing institution, and approved through Consubstantiated Opinion No. 2,151,764, from July 3, 2017, under the Certificate of Submission for Ethical Appreciation No. 67253817.9.3001.5292.
Results
The perceptions of 60 managers about quality in health, who were part of the team of a university hospital, were analyzed. From these, 28 (46.7%) were male and 32 (53.3%) were female, aged between 27 and 66 years. Regarding their formation, there was a predominance of people graduated in Medicine (13; 21.7%), followed by Accounting (9; 15%) and Nursing (7; 11.7%).
Managers with specializations predominated (31; 51.7%), followed by those with master's degrees (18; 30%). 52 (86.7%) participants mentioned having taken a training course in the management field. Regarding the time they worked as managers, there was a variation from 6 months to 34 years, and the time they worked at the institution varied from 9 months to 37 years. Through the DHC of the managers' testimonies, 593 text segments were analyzed, retaining 82.0% of the total texts for elucidating the classes (Figure 1).
Figure 1 - Dendrogram of the Descending Hierarchical Classification of the managers' perceptions and experiences about health quality. Natal, 2019
* EBSERH - Brazilian Hospital Services Company
The typical vocabulary of class 1 allowed the contextualization of the “Influence of the management model”, responsible for 29.0% of the text segments analyzed within the scope of the corpus. The words “hospital” and “EBSERH” denote how the managers conceive the influence of the management model in the promotion of quality in health, especially when employees with different employment bonds coexist, which can influence the feeling of “belonging to the team ”, a feeling that, according to the managers, influences the search for quality in health, as can be seen in the following statements:
You also find it difficult to manage a hospital because you have two groups of professionals who have different employment bonds. (Manager 1)
Today, there is a great dissatisfaction of two different groups, one from the Unique Legal Regime [that is, hired through a government selective process with specific benefits and guarantees that are the same for all government employees] and another from EBSERH [a private company], with different requirements and norms, which generates many conflicts. (Manager 30)
In contrast, the words "contract", "teaching", and "great" reveal that managers were concerned with the mission of the institution where they worked. The institution should offer teaching, research, and extension activities, since it is a university hospital, so that quality management should also include aspects related to teaching, as evidenced by these interviewees:
We have some quality issues that the university asks for, we have some quality elements that EBSERH requests, and within the service provision contract with the local SUS manager, we also have some requirements. (Manager 1)
It does not let the hospital focus only on assistance, we also need to focus on maintaining activities of teaching, research and extension. (Manager 4)
As we serve a wide variety of specialties and with our function of teaching hospital, so that we can truly fulfill our role as health professionals, we seek a high quality of the service provided. (Manager 62)
Class 2, “Quality management tools”, represented 29.8% of the textual data analyzed and revealed the strategies used by managers to consolidate the quality policy of the hospitals. The words "tool", "use", "management", "people", and "indicator" denote that managers used quality management tools, which can be seen in the following statements:
This has been a common search for some years, we have been trying to use the tools and in a certain way disseminate the culture of safety and quality. (Manager 2)
Regarding the quality management tools, we plan the actions related to the sector, identify the activities that provide improvements and evaluate the objectives achieved. (Manager 8)
The management strategy that we use is the application of our institutional protocols, where we use our indicators to improve the quality of the assistance provided in the institution. (Manager 34)
When analyzing the quality management tools that were mentioned, it stands out that 26.6% of the interviewees mentioned planning as one of the or the only quality tool used and 13.3% said they use the Continuous Improvement Cycles. Tools such as the Ishikawa diagram, the SWOT matrix, flowcharts, and cause and effect diagrams were also cited. The use of indicators and spreadsheets was cited as a form of internal analysis by 26.6% of the managers interviewed. The use of software that helps management was also identified.
The managers also mentioned, as management actions that help in the search for quality within the university hospital, the training of professionals, the search for humanized care, and good communication within the team and between different teams and sectors. However, it should be emphasized that 11.6% of respondents said they did not use quality tools in their work.
Class 3 was entitled “Conceptions of quality in health” and represented 25.3% of the analyzed corpus. The main words of this class were: “patient”, “client”, “health”, “service”, and “group”. The managers' conception of quality in health is aligned with the idea of quality as a multifactorial element that results from an interprofessional work process, as highlighted in the following statemenst:
Quality in health represents the result of a group of factors aimed at making the care process safe, accessible and guided by scientific knowledge, with a higher index of evidence and above all aimed at a care based on ethical humanization and responsibility. (Manager 28)
Quality in health is a group of tools and work strategies aimed at improving the work process and providing safety to both patient and professional. (Manager 31)
Quality in health involves institutional behavior, a qualification of professionals, a qualification of the service systems, whether administrative or assistance-related, where this group of improvements would lead to an appropriate assistance to the client. (Manager 64)
Finally, class 4, “Health promotion actions”, which comprised 15.8% of the textual segments, highlighted the words “environment”, “treating”, “respect”, “physical”, and “social”. This class regards elements that work to promote the health of the user and the worker, so that a quality assistance can be offered. According to this conception, satisfaction is an important aspect of quality in health, both from the perspective of their clients and their employees:
Quality also involves acting collectively, being ethical towards others, having respect, cordiality, and being honest, obeying ethical principles that you acquire during your formation. (Manager 4)
We have to treat the patient with all the necessary actions in all areas of the hospital, in order to provide physical and mental well-being. (Manager 62)
Quality in health for me is everything that we can provide our collaborators so that they can be well in the physical and in the social dimensions, because one thing interferes with the other. (Manager 66).
Other words were highlighted in class 4 as "psychological", "life", "disease", and "relationship". Other important words were “mental” and “favorable”, which appeared in 100% of the class 4 text segments and reveal the concern with the worker as an essential aspect of quality in health:
Quality in health is the management agent or collaborator being attuned to the fulfillment of their professional demands with physical and mental disposition to also feel responsible for the effective participation with their client or patient. (Manager 30)
For us to be able to develop quality work, it is important that we also provide an environment favorable to it. (Manager 66)
It can be understood, therefore, that the managers' perceptions about quality in health permeates elements related to management, employees, and clients, which involves structural aspects (adequate work environment, for example) and the work process (such as the use of quality management tools to plan and evaluate), in search of satisfaction to everyone and to the improvement of health care.
Discussion
In the midst of the diversity of professionals in the health sector, the manager presents himself as a fundamental part for the actualization of actions aimed at reaching quality. Thus, the manager must be primarily educated with regard to the functioning of the health service on macro and micro scales, in addition to having the instruments to guarantee an adequate functioning of health services, meaning that scientific knowledge about quality in health is an essential condition to its management.3
However, it is known that scientific technical unpreparedness directly influences the way in which the strategies are implemented and the dynamics of the teams involved in the services, which leads to the inefficiency of the processes.6-7 Thus, an adequate permanent education process for the health manager can directly reflect on the quality of the service.
It can be understood, therefore, that a health institution will have a different performance from the moment the management is under the responsibility of a professional with technical knowledge related to the administration and mastery of health matters.7 In this context, it is highlighted that the management based on continuous assessment processes focused on the premise of quality can assist in making decisions consistent with reality, from the perspective of an effective and efficient management.1-2
Thus, studies related to quality management in health services are emerging, and are necessary for the cohesion between the various sectors in the formulation of effective practices, by bringing crucial elements for quality care that permeate the promotion of a culture of quality.8 Currently, the culture of quality is defined as the product of values, attitudes, competences and patterns of individual and group behavior, which determine the commitment, style and proficiency of the management of a healthy and safe organization.9
However, it has been pointed out that high ranking hospital management still seldom acts in issues involving quality in health and patient safety, which implies a negative culture and the discouragement of health professionals who work in the line of care. For this reason, managers are emphasized as essential in the search of high quality in health, since they are responsible for promoting an open environment of sharing and trust, in order to lead their team through effective communication, promoting professional development, through training, encouraging safe practices, and providing feedback.10
The perceptions of the research participants in class 1 were in line with the idea that the management model influences care and, consequently, its quality. Regarding this, with the advent of the Brazilian Hospital Services Company (EBSERH), a public institution with the objective of managing hospital units, a shared management seeking the restructuring of university hospitals started. This whole process was conceived to promote improvements in management, but it culminated in countless conflicts, constituting intense democratic debates with positions in favor and against the institution, especially regarding the its workers.11
The conflict which was addressed the most during this research is related to the employment bonds, since the workers of public companies are under the regime of CLT (Consolidation of Labor Laws, the group of laws that regulate most long-term work bonds in the country), unlike the other professionals, who are under the Single Legal Regime (RJU). Under the CLT, the employment relationship is contractual between the employee and the administration. The public servants governed by the RJU can be assigned to EBSERH, but their work regime will not be changed. All these factors directly affect the relationship between these professionals and, consequently, affect the quality of care, 12 since teamwork is a fundamental condition for the quality of health care.4
The conflict between employees, in this setting, can be a cause for concern regarding quality in health policies. This is because intermediate and high complexity assistance, more precisely in the hospital area, have been highlighted as an important situation for problems in health care, which permeate both structural elements and working conditions. Thus, in this context, an aligned and qualified human resource with common actions and conceptions become germane for quality in health.13
It is worth mentioning that in the hospital, decisions that are capable of defining the limit between people's life and death are made, both in terms of assistance (the decision for treatment, for example) and management (as is the case for the decision to purchase equipment, for example). Also, in this context, these decisions are accompanied by complex technologies and more invasive procedures, which generates fear and insecurity for those who use this service. Thus, ensuring the quality of care from its conception to its completion is essential.14-15
Considering this, researchers talk about multiple failures that occur in the provision of care, characterized by insufficiencies in work processes and deficient structures, which, once together, constitute paths that cause damage that is often irreversible.16 This is the discussion on patient safety, one of the dimensions of quality in health9 that has been increasingly discussed and consolidated within the scope of health institutions.
Such consequences come from errors or violations committed by people involved in the provision of care (active failures) and from decisions related to the design and control of the processes, as well as their conditions to perform these activities, such as insufficient human resources, inadequate training, among others (latent failures).16 This discussion permeates the managers' concern both with the conflicts experienced by the employees (class 1), and with the search for their satisfaction (class 4), understanding that the employee needs to be involved in the search for quality in health.
Therefore, the concept of quality includes a triad: structure, that its, the resources available for effective assistance (physical, human, material, and financial); processes, such as activities involving professionals and patients, based on accepted models; and the result, which refers to the final product of the assistance provided, that meet the standards and expectations.4,17
The implementation of systems with a focus on quality requires an approach that recognizes the importance of producing actions that enable efficiency and effectiveness, as well as the optimization of results and the satisfaction of clients and employees.18 This concern with quality is a parameter mentioned by the interviewed managers. In the results found in class 2, it was revealed that there is a focus on the Quality Management Systems (QMS), which have been increasingly common in recent years in various organizations. Planning, process review and performance monitoring, as well as constant improvements, have become vital for the performance of management.19
Quality management is understood as a group of actions that covers the different fields of care delivery (materials and services) focused on developing resolutive assistance, which is presented as a vital strategy so that health services can be offered within its concepts and definitions.3 However, these actions do not happen at random and it is necessary to follow crucial points for achieving excellence in the service. So, it is necessary to investigate and monitor the processes by means of instruments based on the best evidence applicable to reality, analyze the functioning of the structures and define whether the results are compatible with the expectations.3,18
Thus, planning actions presents itself as a management tool that boosts practices aimed at articulating work processes and improving quality indicators.20 Considering this, in class 3 it was found that quality in health and their evaluation are relevant topics among managers, and aim to constantly improve care. In the hospital setting, evaluation is seen as a priority for the quality management since the service flows and the needs of users are directly influenced by it.21
In relation to the management, managers have resources that help them in planning, such as: Ishikawa Diagram, Brainstorming, Indicators, Cause and Effect Diagram, Continuous Improvement Cycle, among others, which, in general, serve as managerial elements of study that help in the establishment of uninterrupted improvement of assistance.3 These are called quality management tools, and were cited by managers in classes 2 and 3.
In class 4, it was shown that health promotion and quality of care have a direct association, considering that they consist of a method that clearly shows the risks and damages, in which the well-being of professionals and users is assured.22 Thus, it was noted that managers understood satisfaction as an important dimension of quality in health.
In the hospital environment, health promotion, with the objective of providing high quality care for both users of the system and for workers, is essential in order to minimize or reduce the potential risks that may affect the health of those involved.23 Different strategies can be used to constantly improve the offer of assistance. Considering the individual dimension, the objective is in self-knowledge and behavioral measures; in the collective/organizational environment, the objective is the execution of educational activities, courses, and continuing education for professionals, as well as the regulation and applicability of legislation and policies. The importance of intersectoriality for a comprehensive care in the execution of interventions must be emphasized.24 Thus, the integration between teams to offer qualified health care is a key factor.
Conclusion
It was revealed that the managers of the university hospital under study related quality to the potential of the service to solve the health problems of the users, as well as to a good relationship between professionals and the consequent improvement in the work process. To consolidate quality management in their work environment, they have used tools, with emphasis on the use of health planning and quality indicators.
Some limitations were found in the performance of the study, such as the fact that the study portrays a local reality. Therefore, the results must be understood from this perspective.
This research is expected to contribute to the dissemination and promotion of a greater debate on the topic addressed, so that the understanding managers have of health quality and quality management tools can be improved, bringing benefits to the assistance provided and improvements in health management. In addition, it is believed that, by presenting a more detailed characterization of the performance of managers, as well as of their conceptions, the study can provide information that supports important interventions to change reality, such as the permanent discussion of quality in the scope of services of health, seeking to transform it into a strategic policy that involves the different levels of management in favor of better health care.
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Chief Scientific Editor: Cristiane Cardoso de Paula
Associate Editor: José Luís Guedes dos Santos
Corresponding author
Pétala Tuani Candido de Oliveira Salvador
E-mail: petalatuani@hotmail.com
Address: Escola de Saúde, Universidade Federal do Rio Grande do Norte, Lagoa Nova, Natal, RN, Brasil
CEP: 59078-970
Author contributions
1 – Sâmia Jamylle Santos de Azevedo
Data collection, data analysis and interpretation, writing and critical review.
2 – Larissa Kelly Silva de Moura
Data collection, data analysis and interpretation, writing and critical review.
3 – Camila Matias Nascimento
Data collection, data analysis and interpretation, writing and critical review.
4 – Theo Duarte da Costa
Conception and planning of the research project, data collection, data analysis and interpretation, writing and critical review.
5 – Pétala Tuani Candido de Oliveira Salvador
Conception and planning of the research project, data collection, data analysis and interpretation, writing and critical review.
How to cite this article
Azevedo SJS, Moura LKS, Nascimento CM, Costa TD, Salvador PTCO. Percepções de gestores de um hospital universitário sobre a qualidade em saúde. Rev. Enferm. UFSM. 2020 [Acesso em: Anos Mês Dia]; vol.10 e95: 1-18. DOI:https://doi.org/10.5902/2179769243697