APPLICABILITY OF QUALITY MANAGEMENT TOOLS FOR EVALUATING PROCESSES IN PRIMARY HEALTH CARE

Abstract

Objective: The objective of the study was to understand the role of health managers in primary care, using validated quality tools, created and implemented within the Unified Health System (SUS). Method: This is a bibliographical review, of an exploratory and descriptive nature, developed using the qualitative method, through published scientific articles and literary works, without a time frame, in the Portuguese language. The Virtual Health Library (VHL) databases were used, specifically LILACS and MEDLINE, and BDTD, Google Scholar, SciELO and CAPES journals. Results and conclusion: The literature review identified that the quality tools validated in the SUS can be used by health managers to improve primary care, helping them to develop strategies to improve the provision of care to users. Among the tools identified, the PCATool-Brasil instrument was considered the most complete, as it evaluates primary care in several aspects, such as organization, access, care process, effectiveness and user satisfaction. Research implications: The research results indicate that quality tools validated in the SUS can be an important tool for health managers in improving primary care. However, it is important that managers adapt the tools to their local reality, taking into account the most relevant indicators for their population. Originality/value: The study is original because it presents a bibliographical review that addresses the role of health managers in primary care, using quality tools validated in the SUS. The study is also relevant for identifying that the PCATool-Brasil instrument is a complete tool that can be used by health managers to improve primary care.

Alternate abstract:

Objetivo: O objetivo do estudo foi compreender o papel dos gestores de saúde na atençâo primaria, utilizando as ferramentas de qualidade validadas, criadas e executadas dentro do Sistema Unico de Saúde (SUS). Método: Trata-se de urna revisäo bibliográfica, de caráter exploratorio e descritivo, desenvolvido pelo método qualitativo, através de artigos científicos publicados e obras literárias, sem recorte temporal, no idioma portugués. Foram utilizadas as bases de dados da Biblioteca Virtual em Saude (BVS), específicamente na LILACS e MEDLINE, e BDTD, Google Académico, SciELO e periódicos da CAPES. Resultados e conclusâo: A revis&acaron;o bibliográfica identificou que as ferramentas de qualidade validadas no SUS podem ser utilizadas pelos gestores de saúde para melhorar a atençao primaria, auxiliando-os no desenvolvimento de estrategias para melhorar a prestaçâo assistencial aos usuarios. Dentre as ferramentas identificadas, o instrumento PCATool-Brasil foi considerado o mais completo, pois avalia a atençao primaria em diversos aspectos, como organizaçâo, acesso, processo de cuidado, efetividade e satisfaçao dos usuarios. Implicaçöes da pesquisa: Os resultados da pesquisa indicam que as ferramentas de qualidade validadas no SUS podem ser urna importante ferramenta para os gestores de saúde na melhoria da atençao primária. No entanto, é importante que os gestores adaptem as ferramentas à sua realidade local, levando em consideraçâo os indicadores mais relevantes para a sua populaçao. Originalidade/valor: O estudo é original por apresentar uma revisâo bibliográfica que aborda o papel dos gestores de saúde na atençao primária, utilizando as ferramentas de qualidade validadas no SUS. O estudo também é relevante por identificar que o instrumento PCATool-Brasil é urna ferramenta completa que pode ser utilizada pelos gestores de saúde para melhorar a atençao primária.

Headnote

ABSTRACT

Objective: The objective of the study was to understand the role of health managers in primary care, using validated quality tools, created and implemented within the Unified Health System (SUS).

Method: This is a bibliographical review, of an exploratory and descriptive nature, developed using the qualitative method, through published scientific articles and literary works, without a time frame, in the Portuguese language. The Virtual Health Library (VHL) databases were used, specifically LILACS and MEDLINE, and BDTD, Google Scholar, SciELO and CAPES journals.

Results and conclusion: The literature review identified that the quality tools validated in the SUS can be used by health managers to improve primary care, helping them to develop strategies to improve the provision of care to users. Among the tools identified, the PCATool-Brasil instrument was considered the most complete, as it evaluates primary care in several aspects, such as organization, access, care process, effectiveness and user satisfaction.

Research implications: The research results indicate that quality tools validated in the SUS can be an important tool for health managers in improving primary care. However, it is important that managers adapt the tools to their local reality, taking into account the most relevant indicators for their population.

Originality/value: The study is original because it presents a bibliographical review that addresses the role of health managers in primary care, using quality tools validated in the SUS. The study is also relevant for identifying that the PCATool-Brasil instrument is a complete tool that can be used by health managers to improve primary care.

Keywords: Health Services Evaluation, Primary Health Care, Quality Management in Health, Tools.

RESUMO

Objetivo: O objetivo do estudo foi compreender o papel dos gestores de saúde na atençâo primaria, utilizando as ferramentas de qualidade validadas, criadas e executadas dentro do Sistema Unico de Saúde (SUS).

Método: Trata-se de urna revisäo bibliográfica, de caráter exploratorio e descritivo, desenvolvido pelo método qualitativo, através de artigos científicos publicados e obras literárias, sem recorte temporal, no idioma portugués. Foram utilizadas as bases de dados da Biblioteca Virtual em Saude (BVS), específicamente na LILACS e MEDLINE, e BDTD, Google Académico, SciELO e periódicos da CAPES.

Resultados e conclusâo: A revis&acaron;o bibliográfica identificou que as ferramentas de qualidade validadas no SUS podem ser utilizadas pelos gestores de saúde para melhorar a atençao primaria, auxiliando-os no desenvolvimento de estrategias para melhorar a prestaçâo assistencial aos usuarios. Dentre as ferramentas identificadas, o instrumento PCATool-Brasil foi considerado o mais completo, pois avalia a atençao primaria em diversos aspectos, como organizaçâo, acesso, processo de cuidado, efetividade e satisfaçao dos usuarios.

Implicaçöes da pesquisa: Os resultados da pesquisa indicam que as ferramentas de qualidade validadas no SUS podem ser urna importante ferramenta para os gestores de saúde na melhoria da atençao primária. No entanto, é importante que os gestores adaptem as ferramentas à sua realidade local, levando em consideraçâo os indicadores mais relevantes para a sua populaçao.

Originalidade/valor: O estudo é original por apresentar uma revisâo bibliográfica que aborda o papel dos gestores de saúde na atençao primária, utilizando as ferramentas de qualidade validadas no SUS. O estudo também é relevante por identificar que o instrumento PCATool-Brasil é urna ferramenta completa que pode ser utilizada pelos gestores de saúde para melhorar a atençao primária.

Palavras-chave: Avaliaçao de Serviços de Saúde, Atençao Primária à Saúde, Gestao de Qualidade em Saúde, Ferramentas.

1 INTRODUCTION

Currently, the search for quality of care and excellence in the care provided to individuals, whether in primary, secondary, or tertiary care is considered a gold standard.

In the sphere of the Unified Health System (SUS), primary care is considered as a gateway to public services, being responsible for health practices that imply actions of promotion, protection, prevention, diagnosis and treatment, included in the item treatment, rehabilitation, and palliative care, besides monitoring the primary health system and the reduction of harm caused by health care practices, whether of collective, individual or family nature (Brazil, 2017 apud Silveira; Hoffman, 2021).

According to Souza et al. (2022), the monitoring of health services becomes indispensable and paramount for managers, since through this monitoring, they will be able to draw up new strategies and goals to be applied in their services, thus favoring decision making.

In this sense, for Ferreira, Neves and Rosa (2022) measuring quality in primary health care is considered a challenge, considering the existence of numerous factors that interfere and influence demand and results, in addition to the complexity of services provided to users (Ferreira; Neves; Rosa, 2022).

In addition, quality management aims to provide both health managers and their users, based on the triad structure, process and results, with best care practices aimed at excellence in care, thus favoring decision-making (Nascimento et al., 2023).

In this respect, for Ferreira et al. (2018), quality indicators act as an instrument, able to help health managers, to assertively trace their goals and behaviors, acting as a guiding tool in relation to public policy making and health planning.

In view of the above, the present study raised the following guiding question: how can instruments validated and used by quality management actually contribute to the evaluation of care and epidemiological processes in basic health care?

In this sense, the objective was to understand the role of health managers in primary care, using the quality tools validated, created and executed within the Unified Health System (SUS) and, understand the functionality of the tools and how they can help develop strategies to improve care delivery to users.

2 MATERIALS AND METHODS

This study brings an exploratory and descriptive approach, in which the qualitative methodology was adopted, based on published scientific studies, based on the theme, thus answering the questions raised in this study.

The data collection was subsequently carried out between the period of March to September 2023, using as criteria for selection, the scientific articles published in their entirety, without time-lapse, in the Portuguese language, always based on the descriptors selected previously: evaluation of health services, primary health care, quality management in health and tools. To do so, research was carried out in databases such as the Virtual Health Library, Google Academic, the Brazilian Digital Library of Theses and Dissertations (BDTD), the SciELO (Scientific Electronic Library Online), the Cognitionis Magazine and CAPES magazines.

As an exclusion criterion, the following criteria were adopted for the selection of the scientific articles that contributed to the preparation of this study, in addition to the previously selected descriptors: (1) duplicate articles, (2) in foreign language, (3) not being available in full.

Detailed readings of the selected materials were carried out, in order to verify if in fact the selected material previously meets the purposes adopted by the study. Based on the previous reading and analysis of the selected material, a structured data collection instrument was developed, containing title, author, source and year of publication, according to Table 1.

In this sense, 16 literary works were selected, which serve the object and main purposes of the study, and these are applied as bibliographic reference.

3 THEORETICAL FRAME

3.1 Role of Health Managers in Primary Care

Regardless of the care complexity in the care provided to the user, of the Brazilian Health System, managing their quality becomes imperative for the proper functioning. According to Starfield (2002, p. 419), when:

[...] of high quality are concerned not only with the adequacy of services for the diagnosis and management of diseases, but also with the adequacy of services that prevent future diseases and promote improvements in health.

Primary Health Care (PHC), the gateway to a universal service network, should coordinate care and promote completeness (Cubas et al., 2017). The Ministry of Health (MS) prioritizes public management based on induction, monitoring and evaluation of processes and measurable results to ensure access and quality in health care for the entire population (Cubas et al., 2017; Brazil, 2014).

In this sense, it would also be no different in the field of basic health care (Cubas et al., 2017). In this way, the National Basic Care Policy (PNAB) has been adjusted to recognize and stimulate the quality of the services offered, especially in the Family Health Strategy (FHS), which reaches more than half of the population (Brazil, 2017 apud Lima et al., 2021).

With this, it was necessary to create models of administration that would serve basic health services, having as priority the planning and strategic and appropriate care flows, without reflecting significantly on the access to services provided to users to the health system (Brazil, 2017 apud Lima et al., 2021).

For this, effective coordination of care, ensuring continuity in services, is essential to achieve high scores. Challenges include appointment of appointments and integration with specialized services, highlighting the need to leverage the PHC as the ordering center of the service networks (Costa et al., 2020).

In addition, the need to cultivate an evaluative culture in the managing instances of the SUS, including the perspective of professionals in the Basic Health Units (BHU), is highlighted. Actions to improve primary care include evaluation programs integrated with management practice, strengthening decentralization and autonomy. Interventions in permanent education and training of managers are essential for effective evaluative practices at APS (Ferreira; Neves; Rosa, 2022).

Therefore, the issue of the quality of management and practices of PHC teams became crucial for SUS managers (Brazil, 2014) to measure results and guide public policies and promote advances in the local health system. Hauser (2012, p. 25) states that:

[...] quality evaluation in health services is an important measure of the decisionmaking process by managers and employees, such as, for example, in the prioritization of investments, in the subsidy to identify problems and help in the reorientation of actions and services provided to the population.

According to Savassi (2012), restructuring the entire production chain of public health services is a challenge to be faced by public managers, considering that it is necessary to make paradigm breaks and make changes in organizational culture.

However, measurement of results, although challenging given the complexity of performance, influence of determinants, and diversity of services offered, is necessary. It is stressed that this assessment is affected by the population profile, local characteristics and socio-economic factors. Therefore, vertical quality programs require engagement for continuity and effective change. (Ferreira; Neves; Rosa, 2022).

Finally, health managers must prioritize quality, sustainability and efficiency, where management tools, such as customer satisfaction assessment, are essential to analyze performance and guide decisions. Evaluating satisfaction subsidizes planning and actions, with a focus on meeting real needs. However, three related critical aspects are technical attention, interpersonal relationship and physical environment (Lopes; Xavier, 2022).

3.2 Tools Functionality and the Search for Differentiated Strategies

Using tools able to assist health managers in the evaluation of health services primarily in the field of basic health care, can show them, the possible weaknesses and potentialities of a service, based on the principles and guidelines of primary health care, focusing on the unit's infrastructure, team management and workflow (Santos et al., 2023).

As far as the satisfaction of the users of the system is concerned, a study showed that there is no standard adopted in the network and the management uses different evaluative questionnaires, which can harm comparisons. Thus, the need for a specific reference point for health services satisfaction research in Brazil is highlighted (Lopes; Xavier, 2022).

Thinking about the quality of care in basic Brazilian health, it was initially created through the ordinance of No. 1654 of 2011 and revoked through the ordinance of No. 1645 of 2015 the National Program for Improvement of Access and Quality of Basic Care (PMAQAB). According to an instructive manual prepared by the Ministry of Health:

The main objective of the program is to induce the expansion of access and the improvement of the quality of basic care, with a guarantee of a comparable quality standard nationally, regionally and locally, so as to allow for greater transparency and effectiveness of government actions directed towards Primary Health Care (Brazil, 2014, p.7-8).

Based on the PMAQ-AB, assessment tools have been developed, validated and adopted by primary health care to help health managers make better decisions and ensure the quality and excellence of health services provided to users. The instruments to be addressed in this study will be: assessment for the improvement of access and quality of primary care (AMAQ) and the Brazilian Primary Care Assessment tool (PCATool- Brasil).

The Access and Quality Improvement Assessment (AMAQ) is a self-assessment tool designed and designed by the Brazilian Ministry of Health, to be used and applied exclusively in the family health strategy, functioning as a measurable tool, contemplated with information on the provision of the services provided and their adequacy (Nascimento et al., 2023).

However, the instrument created by the Ministry of Health does not take into account the perceived experience of the user in relation to the use of primary public health services, this being considered an indispensable item when it comes to assessing the quality of health services provided to users (Pereira, 2018 apud Nascimento et al., 2023).

According to Brasil (2016, p. 15), "[...] the use of AMAQ is not mandatory, it is up to municipal managers and primary care teams to define the instrument(s) or tool(s) that best suits their needs and realities."

Consequently, the Brazilian Ministry of Health opted to exchange the National Program for Improvement of Access and Quality (PMAQ) for an instrument that is capable of better evaluating, analyzing and validating the performance of primary health teams, also contemplating the patient experience and the global indicators of assessment of care quality (Brazil, 2020), known as PCATool - Brasil or Primary Care Assessment Tool Brazilian version (Primary Care Assessment Tool).

For Cubas et al. (2017, p. 474), the "[...] PCATool-Brasil evaluates the attributes of PHC, of which four are exclusive - access, longitudinally, completeness and coordination - and two are derived - family orientation and community orientation".

Costa et al. (2020), say that the PCATool provides managers, in primary health care (PHC), an evaluation of their workflows in a more successful way and with low operational cost, with better assimilation and functionality, in the provision of health care to users.

4 FINAL CONSIDERATIONS

The present study aimed to understand the role of health managers in primary care, using the validated quality tools created and implemented within the Unified Health System (SUS), and to understand the functionality of the tools and how they can help develop strategies to improve care provision to users, in which the main objective was achieved.

Through the use of quality indicators, health managers, regardless of the level of attention, can visualize possible failures, be it assistance or administrative, and can align their objectives and assistance actions, with the strategic priorities.

In this context, addressing the issue of quality in basic health care has become a fundamental issue, given the reforms that have taken place in the last decades in Brazil's unique health system.

It is important to emphasize that it is up to the health manager to develop criteria to be analyzed by indicators according to their local reality, always taking into consideration their functional impact, prevalence, incidence, operational costs and their effectiveness.

By means of a comparative analysis between the tools validated and used in the Brazilian Unified Health System, used to evaluate the care processes and their implementation in primary care, such as the instrument of Evaluation for the improvement of Access and Quality in Primary Care (AMAQ) and the Brazilian version of the instrument of Primary Care Assessment, known as Primary Care Assessment tool (PCATool- Brasil), it was observed that the instrument PCATool-Brasil better meets the needs of basic health in Brazil because it takes into consideration the evaluation of the essential and derived attributes of primary health care.

In relation to the Assessment Instrument for Improving Access and Quality in Primary Care (AMAQ), the instrument is considered very limited, which requires health teams and health managers to collect more data and time to complete the evaluation items, as well as not providing sufficient transparency in the collected data, leaving gaps for the numerous ways of interpreting the inserted data.

Furthermore, it is important to always emphasize that not only health managers go through the process of professional qualification, but also their entire multidisciplinary team, considering the need to align their basic health units to provide excellent services to their users, aligned with strategic priorities.

Further targeted studies are needed in the subject addressed, considering that, despite the importance of the theme, there are still few targeted publications.

References

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