Decision making and senior management : the implementation of change projects covering clinical management in SUS hospitals

This paper analyses the decision making process for senior management in public hospitals that are a part of the National Health Service in Brazil (hereafter SUS) in relation to projects aimed at changing clinical management. The methodological design of this study is qualitative in nature taking a hermeneutics-dialectics perspective in terms of results. Hospital directors noted that clinical management projects changed the state of hospitals through: improving their organizations, mobilizing their staff in order to increase a sense of order and systemizing actions and available resources. Technical rationality was the principal basis used in the decision making process for managers. Due to the reality of many hospitals having fragmented organizations, this fact impeded the use of aspects related to rationality, such as economic and financial factors in the decision making process. The incremental model and general politics also play a role in this area. We concluded that the decision making process embraces a large array of factors including rational aspects such as the use of management techniques and the ability to analyze, interpret and summarize. It also incorporates subjective elements such as how to select values and dealing with people’s working experiences. We recognized that management problems are wide in scope, ambiguous, complex and do not come with a lot of structure in practice.


Introduction
In the last decades, the process of changing public policies in Brazil has gained prominence due to the realignment in the direction of reforms from the federal Government which involves improving the make-up of the primary health care network.With specific reference to social policies, there has been a redefinition in the functions and possibilities involved in the administration of public bodies that are responsible for providing services directly to users [1][2][3] .This has occurred due to the increasing costs in health services.
The increase in health care expenditure and the efficient use of public resources which constitutes the main source of financing in this area, has stimulated debates and has given rise to the implementation of strategies to modify access to health care and improve its quality.
Health care is an area that involves technical discussions and debates around policies, projects and strategies for implementing reforms with the acceptance that this area is complex and that this complexity has ramifications at all levels of government 4,5 .In this ambit, hospitals stand out as one of the main organizations in relation to the above due to providing medium and highly complex medical interventions and because they consume a considerable amount of resources to provide these services 6 .Continuing on this vein, when the discussion is on primary health care in SUS, hospitals and the innumerable aspects that surround them ought to be taken into consideration 6 .
According to Barbosa e Gadelha 7 , even if hospitals could improve their performances through conducting more complex interventions and through the use of modern innovative technology, it would still take a while to progress because studies have shown they are still in their embryonic phases with many significant challenges ahead.For the authors, it is firstly necessary to have an analytical understanding of innovation in hospitals.According to them, another alternative would be to develop a new perspective on management in hospitals and generally in the health system.According to the aforementioned authors, there are many challenges to be overcome in state hospital organizations in SUS.Due to limits that are placed on them in relation to the services that it can be provided, they are viewed as organizations that have little innovation.
Coupled with this limiting scenario, hospitals are considered to be institutions that resist changes because: "there is little interaction between professions and departments, clinical practices are fragmented, users of the services are greatly subordinated and there is little corporate governance" 8 .
The public administration is seen as: having little capacity for operational governance, being weak at making decisive decisions, not having any controls and generally not having the ability to govern.In this context hospitals are seen as places with poor or outdated technology and old management practices.Public hospitals have increasing costs and the majority are not efficient.Their results are poor and their quality of service leaves a lot to be desired [3][4][5] .
Ibañez and Vecina Neto 5 stated that, "The ability of the professional to manage complexity in hospitals, which is strongly linked to technological innovation and entrepreneurial practices, is one of the main challenges in public management today." Aside from the difficulties in public management the decision making process in organizations that involve strategic dimensions and administrative rationality, what are also present are incongruities.Leaders and managers in this area should not only be au fait with the technical, scientific and predictable aspects in the behavior of organizations, they must also be familiar with the informal and unpredictable in organizations.For hospitals, this means understanding: the professional functions of the organization, the process of providing health services, the network of relations with the organization and the environment and the needs of the community including its demographics and development 9,10 .
Studies on hospitals that advocate the implementation of change projects bring not just strategic understanding to face the challenges, but also support for the building of rational and effective planning that will help in hospital management.
These projects can aid in improving clinical management in hospitals.According to Mendes clinical management can be understood in the following way: "A group of clinical micro-management technologies that aim to provide quality services in primary health care.It is people centered and is based on science.It is safe as it does not cause damage to the patients or health care professionals.It is efficient and provided at the best costs.It is also considered opportune and given at the right time.It is seen as equitable in that it reduces inequalities and it provides humanized services" 11 .
Clinical management relates to the organization of primary health care aiming to ensure that health care professionals are involved in the management of resources and services.The idea is to use management tools for constructing health care management.There needs to be decentralization as well as autonomy and co-accountability 12 .
Based on the above understanding, the purpose of this study is to objectively analyze the decision making process of senior management in public hospitals in SUS in relation to projects aimed at changing clinical management.
In order to see definitive innovations from the outputs of these projects -which is outside the scope of this study -it is not just sufficient to analyze the decision making process to keep these projects going, it would also be necessary to conduct an evaluation of the results looking at the process of innovation as its scope.If we were to take into consideration the ideas of Christensen et al. 13 , for example, we ought to conduct an evaluation to see if the results of the projects showed ruptures (including the management model) through the transformational force and thus produced improvements to obtain better results allowing greater accessibility to hospitals and better health care.

Theoretical and conceptual framework
Based on the objectives of this study, we centered on the functions of the senior management from the perspective of Hambrick and Taking Decision which was also considered in the same category as the decision making process.
Studies of senior management have been done by many authors and we decided to explore Hambrick's theoretical stance in this area.He stated that senior executives should take strategic decisions based on their cognition and values [14][15][16] .
He states that the senior management is a formal and dominant coalition made up of the main executive and his/her team.Its role is to define the vision or way forward which is just like presenting the philosophy and values of the company.
This area has been studied extensively over the years.The decision making process is important because making correct decisions is crucial for all organizations irrespective of their being public or private entities.These decisions are made all of the time, at all levels and have a direct influence of the company's performance and continuity.It is impossible to think about an organization without taking in account the decision making process.
As this is quite a broad theme it became necessary to narrow down the relevant aspects in relation to the decision making process.We took into account the works of Simon and Schoemaker who focused on rationality and the behavior around making decisions.We also considered the analysis of Etizzioni and Lindblom and we covered policy touched on by Mintzberg.These authors were chosen because they looked at choices that are made before actions are taken and not just on the methods and processes that require coordinated actions involving a group of individuals.
According to Simon 17 , the decision making process is defined as a line of thinking and actions that will culminate in a selection.It consists in choosing alternative courses of actions or even accepting or repudiating a specific act.The decision is inseparable from making the decision because they are part of the same process and they both require analysis and action.This means that analysis and actions have a role to play in the decision making process.They are tools that allow for: the problem to be defined, possible alternatives to be evaluated and finally a decision to be reached 17 .
According to Simon in relation to rationality the decision maker, with reference to his behavior and his integrated systems, will use his wide vision of the available options to analyze the consequences of any choices made and the criteria used to accept a specific option.The decision maker's behavior in reality never follows the script because rationality requires total knowledge and an ability to know the consequences of all the other alternatives 17 .
As there are limits on how much information can be realistically processed, individuals often only take in the amount that their brains can process.Thus a decision is not a rational process where there is a consideration of all of the possible alternatives.It is a simplification of reality adjusted for the human mind.
Taking on aboard the fact that in practice the information is often fragmented and appears in the middle of a series of management tasks, the problems are unstructured and the information systems are limited to past data.
Based on the need to make quick decisions, the decision making process does not following the rational vision but rather is based on intuition and perception of crucial variables.Thus, finding solutions does not solely depend on be-ing rational with the ability to put aside the process of analysis.It is also necessary to experiment, to be flexible, to adapt and be open to continuous learning 17 .
According to Schoemaker 18 , strategic decisions in organizations can be examined under four models: unitary rationality, organization, politics and contexts.Each perspective focuses on the complex reality that involves strategic decisions or the results in organizations which diverge from the objectives and require efficiency.
The decision making process is never genuinely rational like an algorithm.It is characterized as being abstract and symbolic.The product (decisions) can be completely diverse.
The incremental perspective came about through questioning the precepts of the rational vision in the decision making process which was seen as pretentious and distant from the practical reality of the decision maker.In the incremental model that incorporates behavioral assumptions, the decision makers can only be understood as a social actors, in other words, people with cognitive limitations that have constant interactions with other agents.They are involved in social constructions.The idea is to add structure to the decision making process so that there is less centralization and more societal plurality.
The "incrementalist", according to Etizioni 19 and Lindblom 20 , state that the selection of values and empirical analysis cannot come about at different times to each other and without mutually influencing each other.On the contrary, both values and policies are chosen simultaneously as part of an interdependent process.
Lindblom 20 believe that the decision maker, independent of values and objectives, focuses his attention on marginal values and incrementals.
The discussions on the limitations of the decision making process models takes one to search for a model that analyzes both the decision making process and when not to take decisions.It should also take in consideration aspects such as: power, force, influence and authority.From this came about the proposal to analyze the context of the decision making process through the prism of the political question.For Mintzberg 21 , an organization's policy can be analyzed as a constituent and is positioned between the systems and what influences them.Amongst others, one can take into account the system of authority, ideology and competency (forensic and technical).Mintzberg 21 notes that the political arena can be deemed as informal where organizations deal with highlighted conflicts internally.These conflicts are a part of general working relations in the work place and when they occur, they are initially reined in by management.The belief is that if they worsen and spread to the power structure, they would become unbearable for the senior management and sometimes difficult to control.
A specific choice by the authors for these theories and concepts came about due to the need to promote a greater understanding of the intricate reality of hospital directors.This permits an analysis of the main motives in making decisions with reference to maintaining projects.In other words, having the intention and understanding -amongst other aspects -on whether the maintenance of the projects was motivated by the desire to continue with the same actions that were being developed or because the predicted strategy in the projects had been providing positive results.Another motive may be because the actions that were underway, had not gone on long enough to be evaluated in terms of efficiency and effectiveness.

Methodology
This study was a part of a wider study whose general objective was to evaluate the implementation of change projects in the clinical management of hospitals in SUS 12 .This was a qualitative study that obtained approval from the Ethics Committee at the Sírio-Libanês Hospital (HSL).It took place in five SUS hospitals, one in each Brazilian region.The projects evaluated were the final works from the Specialist Hospital Management Course on SUS that was developed by the HSL in partnership with the Health Ministry.
The projects were given the title of Application Projects (PAs) and related to the competency of clinical management.They were developed by groups made up of professionals in every hospital that participated in the course.The process of developing the PAs involved: diagnosis, defining goals and actions and the participation of the hospital teams and those that were studying in the health districts.
The selection of the projects for this study was done in two steps.In the first step, out of the 34 projects for clinical management that were presented on the course, 24 were chosen based on the following criteria: (1) coherence between the project's proposal and the course, (2) carrying out context analysis, (3) clarity of the proposal, (4) defining an action plan, (5) feasibility analysis and identifying, monitoring and evaluating tools for the proposal.
In the second step, (why out of the initial 24 projects that were selected, 5 were left?) for each of the 24 projects, scores from 0 to 10 were given by 2 evaluators.Each of the criterion mentioned was designated a point from 0 to 2. The final score for each project/hospital was the result of the sum of the average scores reached for each criteria.
The selected projects were distributed throughout the respective regions.For each, we selected the project with the highest average.The hospitals connected to the five projects that were selected (one per region) were subsequently contacted.The hospital managers for the three regions did not formally adhere to the study stating that the project had not been fully implemented.The reasons given for their not being implemented were: "changes in management" and "lack of institutional support" or "lack of resources".Based on this, the projects that were classified in sequence in the three regions, were chosen.Therefore, we had five projects for each region in the country, having formal adherence to the research from the hospital managers.These hospital will be mentioned in this study with the following codes: north, north east, central western, south east and south.
The majority of the PAs selected, focused their change objectives on the hospital sector and emergency services with the main focus being on intervention.Even if the PAs had a different focus, as observed in Chart 1, they -directly or indirectly -would be related to clinical management.This is because this was what came out from the course in the three competency areas: management in health, primary health care and education in health.
Aside from an evaluation of the application projects, the methodological strategies for the research were: participant observation in the hospitals, semi-structured interviews with health care professionals and open interviews with hospitals managers.
In the present study, being qualitative in nature, focus is being specifically placed on the interviews with the managers and the reports from the observations that were not submitted to analytical procedures, but were only used to better understand and contextualize the interviews.
The open interview had questions on the opinion of the director concerning the experience of project implementation in the hospital.In cases where the then current director had not participated in the start of the application project, the previous directors were interviewed whenever it was possible.From this, nine interviews were obtained: two from the north east, one from the south east region, two from the central western region, one from the north and three from the southern region.The managers here are nominated by the region to which they belong in their respective regions.
The interviews were analyzed based on the Method for Interpreting Meaning 22 .This method is based on the hermeneutic-dialectical principles that seek to interpret the context, the reasons and the logic of speech, actions and inter-relations between groups and institutions.Therefore there is a search not just for an understanding of the underlying meanings in the interview, but also there is a contextualization of the logic.
Upon analyzing the text produced from the interviews, the following questions were used: What aspects contributed to your taking the decision to keep the implemented projects?How did the managers view the keeping of the implemented projects?What are the differences and similarities between the decisions that were taken in the five hospitals that were studied?
In terms of the analytical trajectory, the following steps were followed: (a) a general read through of the interviews with a view to gaining a general understanding, (b) an identification of the part related to the questions being evaluated, (c) analysis of the expressed meanings or diffi- culties in understanding parts in the interviews, (d) a drafting of a summary for each question, expressing the interviewers meanings from a theoretical and conceptual basis and taking into account related studies in this area.

Characterization of the hospitals that were studied
The hospitals exclusively catered for SUS users.They are large hospitals (having more than 150 beds) and they are very important in the regions which they serve (Chart 2).In certain cases they also cover entire states.This can be explained due to all of them having a particular specialist and complex area in medical interventions which has been recognized by the Health Ministry.
All of them also have specialist outpatient units.All of the hospitals had, as their main access point, their accident and emergency unit.This explains why two of the projects were aimed at the reorganization of this sector.
Being public hospitals they had representatives from the management sectors from both state and municipal levels but none that represented the federal levels.With reference to management, there was no uniformity concerning a legal representative ably qualified.There are services that characterize themselves through direct administration and others through indirect administration in health organizations or foundations that are wholly public.
As a peculiarity we observed differences in what was considered to be priority and what was not.There are hospitals which concentrate on trauma incidents whilst others focus on the area of oncology.Others place more of an emphasis in cardiology interventions whilst other in gynecology/obstetrics.This last aspects is evidenced by what official accreditation the unit has which in turn depends on what care the hospital specializes in.

Clinical management projects used to transform hospital realities
Considering what was expressed in the interviews, the managers noticed relevant changes promoted by the projects in the hospital context which corroborated one of the premises in clinical management that is to enhance the hospital organization through guiding the care process resulting in integral care to the patient in a humane way 23,24 .
We were able to improve [.

..] Today we have a more balance medical team [in A & E], we have a team that fully understand what comes in and what shouldn't enter (north east/2)
What do we look for?Quality in service provision, which is humane and based on scientific knowledge.So we saw that this was possible.

(North)
We greatly improved the structure of our hospital.So when you can make the team take responsibility, you get really significant results (South/3).Another dimension in clinical management that was present in the interviews, was the coordinated and systemized involvement of health care professionals in the management of hospital resources.This also could be checked 23,24 .The central western and northern hospitals showed major progress in administrative efficiency and the optimization of public resources with subsequent social gains.

Legal
The family can take the patient home.This is very important for the family, the patient and the hospital.Freeing up a bed [...] vacating a bed [...] well we've seen the amount of readmissions fall drastically (central western/1).
The south and south east hospitals saw an increase in their professional body which corroborated the idea of looking to develop the leadership abilities of the hospital management team as well as developing protocols, flowcharts and directives based on ethical principles and scientific evidence [24][25][26] .
The institution that I knew when I returned to work, from an administrative point of view, was different and services had been reorganized in the area of clinical management (south east/2).
When we started this process...what emerged was a process that everyone could get involved with.Participatory management occurred as a matter of fact and not something that was merely spoken (south/1).

Aspects that contributed to making decisions
The managers showed very similar motives with reference to the factors that influenced the decisions to keep the projects going.
After analyzing the interviews, it was possible to check that the majority of managers used technical rationality as their principal basis for taking decisions 17,18,27,28 .We saw that they took decisions in limited and fragmented organizational contexts which in the last analysis made it impossible for the use of rationality in the way that they would have liked.They had to deal with problems very quickly and manage their consequences.The managers undoubtedly, would like to hold back greater control in the organizational context through planning and adjusting to their reality to make improvements.However they were often taken by surprised by the level of disunity in the organizational context.It is also worth stating that one manager showed the ability to use variations in the decision making process depending on the problem that he faced.
From the statements given from the north eastern and central western hospitals, there was evidence of the use of the model of the unitary actor mentioned by Schoemaker 18 .This provided evidence of a centralized attitude in taking decisions, in other words a "top down" approach.In spite of not showing a narcissistic perspective, the directors understand that taking decisions can have a strong influence in the allocation, development and use of organizational resources, be there humans or not 29,30 .
I started to imagine that certain actions could only be done if I were in a certain post (north east/1).
At that time I was the technical director and we had the possibility of this type of governance (central western/2) Based on what came out from the professionals looking at the restrictions and difficulties that they face in order to meet institutional objectives, we saw a closeness with the perspective of Schoemaker's organizational model in every hospital sector 18 .This model was used by the south and south eastern hospitals.
You go there and everyone has to explain the result that is there on the wall.Why...it means..the whole team is accountable.(south/1).
This was able to stay deeply inserted in the institution.It works as one body.(south east/1).
Considering the presence of an imaginary discredited figure from the public hospital associated with the search for good operational management, the appearance of positive results related to the project were deemed as critical factors that could be maintained.In the eyes of the managers the positive results would have two actions.They would result in increasing institutional self-esteem stimulating the staff and cool down external political pressure.
Stimulus and the participation of the staff were highlighted in hospitals in the north east, central-western and southern regions as very relevant for the development and maintenance of the projects.Sometimes they were described as an additional force that would be present in the work descriptions of the professionals.This backs up the idea that individuals connect themselves to organizations through links that are affective, imaginary and subliminal 31 .
And so we started off with a team of volunteers...in reality I was the leader and I provided the SAD (house visiting service) doing everything little by little (central western/1) In the southern hospital we saw clear evidence of the presence of the Hambrick and Ma-son 14 concept that the senior management ought to provide a way forward for the institution, giving autonomy so that specific and well defined objectives can be reached.The characteristics and attitudes of the senior management are seen as determinants, in the last analysis, of organizational performance.In this field, the manager states that the stimulus for the workers occurs through publishing, with clarity, the objectives and leading by example.
The director needs to set the tone…the director has to provide focus…because we also showed that in spite of the whole process that we did for our client...we also had, as one of our most important clients, our own professionals.We...we worked a lot to show… what could be improved (south/1).
As referred to earlier, one manager used different approaches in taking decisions.This was the case for the north and north eastern regions.In these cases we also associated their statements with incremental approaches 19,20,32 .
Both described the use of intuition based on the perception of marginal or subjective variables, such as the environment.
There were more difficulties in the past than today.We didn't have the type of A&E unit that we have today...what we have today is a hospital environment.(north/1) The use of political support and support from the community was a significant factor in the north east and central-western regions.The manager stated that keeping the project going became more natural when the population formed part of the processes of adaption and maintaining the project more flexible.This showed participatory and shared management as a way forward, which is necessary for the strengthening of the system as a whole 23,33 .
The practice of public hospital management that is focused on the more technical aspects can be checked through the appropriation of concepts and management tools.The appropriation was mentioned in the interviews as being able to promote the most amount of understanding of the purposes of the institutions as a whole.It was also able to promote, from a political point of view, the construction of a participatory base as a platform for continuous education and a space for discussing the results with the management.This movement involving dialogue, analysis and the development of solutions in the face of demands from the people affected by the project, from the view point of the managers, was greatly relevant for ensuring the participation of the staff.
For Barbosa 34 the increasing complexity of hospitals and what surrounds them does not permit the existence or persistence of decisions that are only based on common sense and past experiences.The competency would be determined by a group of personal factors including innate intuition, aside from experience, but also through the development of knowledge and abilities.Dussalt 35 states that one can impose and put into practice the development of management competencies understood as a level of knowledge (theories, concepts, data) from abilities (the use of knowledge to analyze and organize) and from attitudes (ethical acts).
Having information, people will know everything that we do.You have to have data.You have to have case by case studies.You need to have some measurement.You have to know about it (north/1).
But I believe that our success has progressed.The team always thought beyond the data, facts and real questions (south/1).
Aside from the subjective, political and relational aspects, others that are more tangible such as carrying out pre-tests and the modification of physical structures also appeared to be important for the projects to keep on going.

Maintenance of the project
The statements converged in the sense that the opinion was that keeping the projects, in spite of the benefits, was as or more difficult than implementation.
The movements felt by the managers in opposition to the act of continuing were constant both in and outside the hospitals.
In the hospital context the difficulties that were faced related, principally to, the changes that were taking place and the subsequent resistance from the staff particularly from the unions and councils.This reaffirms Minztberg 21 idea that policies in organizations should be considered as constituents and should be positioned amongst the systems that influence the organization.
There was a high turnover rate of staff.Those people that were trained are not the same as those that are here.(North East/1) A point that has been hotly debated for the last two decades is the negative relations between the lack of effective communication between the sectors and the institutional performance.This was mentioned in the interviews 29 .
In spite of our living in a time where there is a lot of communication on both sides, there is a lack of communication in educational projects that we have....but those that are in the front line feeding off this don't feel part of the project.(North East/1) The managers of the five hospitals were tired of the external policies changes for the institutions.They saw this as a significant factor.Political interference in hospital decisions became a common practice in the whole implementation process and the process of keeping the projects going.
Because there isn't continuity in nothing here.There isn't continuity in governance,....I think it's because of this that we're not progressing as fast as we would like.It's this lack of continuity that I think hamstrings us a lot.(North East/2) Something that is common in the public arena is that changes in the manager, results in changes to everything.(north/1) Now with this lack of continuity in management....it results in causing problems.... Therefore... one way of the other the director didn't have autonomy.We had to appoint people that could be trusted and take out those that were there.(south/2) In this discussion, it all depends on what the politician in power wants at that moment.....So it depends on the political paths.(central western/2) Aside from the political influence, the perpetual struggle between the pressures for production and the quality of the services provided was present in what the managers had to say.This fact became more apparent when the results that came out were slow.In the area that we studied we noted that the dominant concept of immediacy, that is in our modern society, goes against keeping projects going.This is because it affects individuals with the emphasis on politicians who have short term visions 36 .The following were stated as common and prevalent obstacles preventing projects from continuing: the slowness in the responses to the demands in the hospitals, bureaucracy in the transfer of finances and the turnover of staff.
The singular solution that the projects bring, favor continuity.This is the case when the projects are left to continue, as this gives them a sense of longevity in the eyes of the managers.
If a secretary comes in and says that he doesn't want this, he's not going to be successful.Because they are perceptible advances and they help in the lives of people.(north/1) I think there isn't any turning back, there isn't any turning back...this is the way forward, it doesn't make any other sense.(central-western/1)

Similarities
Our analysis of the interviews allowed us to see that many of the problems raised are common to all hospitals and, at the same time, it was possible to look at the solutions that were found such as, for example, the turnover of staff which was highlighted in the north east and north interviews.
Well we've already started to see good results in the people......and what's important is to see how it works when people are not....people are not the most important things, it is the group that is important...when it is something personified it doesn't change.(north/1) The problems of communication between the senior management and those that provide assistance was noted as relevant in the north eastern field, while the opposite was the case for the central western and southern fields: And so there was a group of professionals that took the course, who had strategic positions in the hospitals.And this group, in reality, optimized the implementation of the service (central western/1).
We [the directors] had tasks to comply with and indicators to present.We worked a lot.... ours had to be green... [the results above were set] because exactly.....to show that we were working hard and that's why we were on their backs (south/1).
As there were similarities in the field, we can highlight the difficulties in relation to the political changes and the presence of positive results that support the continuity of the projects.A peculiarity that was not considered strange was in relation to the projects for the entrance and leaving doors for the patient which brought about problems as they were not in line with the SUS network at municipal, state and federal levels.Maybe this could be the starting point for other studies.

Final Considerations
Based on the perspectives of the managers, this study has brought to light the reality of the health care professionals and what they must face in public hospitals in SUS in relation to the continuity of projects on clinical management.
We have shown that the decision making process is a practice that involves rational aspects such as the use of management techniques, the ability to conduct analysis as well as interpret and summarize data.It also includes subjective elements such as the selection of values and consid-

Collaborations
JMC Pacheco and R Gomes equally participated in all of the steps taken to produce this paper.
ering people working experiences.Management problems are often broad, ambiguous, complex and less structured in practice.
The decision making process favors the maintenance of projects.It is a complex act and it is inseparable from the variables that appear in the center of them.The majority of the problems raised in this study were common to all the hospitals that took part.
The technical aspects such as improving medical and administrative flux and increasing hospital efficiency, were not the only criteria to be analyzed in favor of the continuity in the projects.Other salient points came to the fore such as having more community and professional participation in finding solutions to everyday problems 6 .As in other studies, the following were considered relevant factors for managers in taking decisions: a lack of full hospital autonomy, a large dependency in external political decisions and the absence of timely and opportune responses from the health system 9,37,38 .
These considerations cannot be considered as general and definitive, as they come from a narrow qualitative research perspective.They can, however, serve to contribute in the construction of analytical and conceptual categories that can be used as a starting point for future studies in this area.

Chart 1 .
Focus on change projects in clinical management for the selected hospitals.