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

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

doi:10.1590/1413-812320182312.32262016

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OPINION • Ciênc. saúde colet. 23 (12) • Dec 2018 • https://doi.org/10.1590/1413-812320182312.32262016 copy

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

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Abstract

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

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

Principles	Descriptors	Mean	Standard Deviation
1. Focus on health needs and comprehensive care	Health needs - historically constructed - understood as complex phenomena that encompass biological, psychosocial and cultural dimensions. Comprehensive care as an articulated response from professionals, services and different logics to meet individual and collective health needs. Egalitarian assistance regardless of age, sex, religion, sexual option, political option or socioeconomic and cultural insertion. Professionals and managers who agree on common objectives and share responsibilities, aiming to provide comprehensive care for people and populations.	10.00	0.00
2. Focus on outcomes that add value to health and life	Employment of standards to improve clinical efficiency, efficacy and effectiveness, aiming to reduce the use of unnecessary resources and considering the value added to users’ quality of life and health. Use of outcome indicators targeted at the promotion of healthy lifestyles and risk, vulnerability and damage reduction.	8.14	1.57
3. Focus on and responsibility for collective interests	Decision-making oriented by the guidelines of health systems, through the utilization of different perspectives. Accounting in the services/institutions involved in the healthcare network. Guarantee of formal spaces for distinct groups of interest and spaces where they can speak and be heard. Transparency in communication with and provision of information for people, populations, the media and society. Promotion of social control by means of representative colleges.	8.14	2.41
4. Obtention of the maximum benefit, without causing damages, in healthcare.	Reduction in the risk inherent in the care process and increase in the safety of professionals and users of health services. Reduction in damage to the lowest possible level. Variability reduction in clinical decisions and optimization of outcomes based on the best evidences available.	9.57	0.79
5. Articulation of management and clinical-epidemiological rationalities	Incorporation of the clinical-epidemiological and management perspectives into care production. Implementation of processes to monitor clinical decisions with the participation of the individuals involved, promoting professionals’ and teams’ autonomy and accountability. Health professionals’ competence profiles including management capacities as a strategy to provide better responses for people’s and societies’ health needs.	8.43	1.13
6. Articulation and legitimation of different health practices and types of knowledge to face the complexity of health problems	Recognition of the values of patients, users and family, aiming at greater effectiveness. Development of therapeutic plans guided by health needs. Teaching-service partnership to act in the education and qualification of health professionals, articulating the different views of the individuals involved. Multiprofessional teamwork with an interdisciplinary approach. Dialog with popular knowledge in healthcare. Articulation with integrative and complementary practices.	8.00	3.65
7. Power sharing and co-accountability between services and professionals that act jointly in care management	Responsibility for care shared by professionals, patients, users, families, community and managers. Decision-making process of care networks with participation of the services/professionals involved and managerial mechanisms that promote co-accountability and articulation among different environments and levels of care. Accessible, opportune and effective information and communication systems for professionals and services aiming at the qualification of care. Consensual definition of the responsibility of each point of the healthcare network in the promotion of comprehensive care targeted at collective interests. Establishment of articulated cooperation processes among actors (including users) and institutions involved in the healthcare network. Incentive to participation and stimulation of professionals’ autonomy and creativity in the collective construction of care plans. Teamwork, respecting different types of knowledge and potentialities.	7.86	3.67
8. Recognition of the other as a legitimate subject in shared decision-making	Patient/user as subject in care management, with legitimate opinions and desires. Decisions about care shared in the team. Educational actions grounded on respect for and acceptance of people as legitimate subjects in the decision-making about their own health and way of dealing with life.	7.57	3.82
9. Adoption of reflectiveness, in which thought and action co-exist and influence one another in the reproduction and transformation of practices	Reflective dialog between clinical management actions and information about the reality where these actions are inserted. Understanding clinical management activities as activities that can be reviewed in light of new information. Permanent assessment and reformulation of clinical management practices in light of new information.	8.00	3.70
10. Recognition of people’s and organizations’ capacity to learn how to learn in view of the incompleteness of knowledge	Recognition of the importance of innovation and improvement in care processes. Recognition of the effort to overcome difficulties or limitations in health work. Promotion of patients’, family’s and teams’ autonomy in health production. Amplified investigation of health needs with formulation of questions and hypotheses in the identification of problems and care production. Development of educational practices that respect and consider the previous knowledge of all the people involved. Educational practices that take into account the individual sociocultural context and the service’s, institution’s or network’s context. Knowledge and learning production based on the reality of health work and on problems of the daily routine, with encouragement to critical and reflective thought and transformation of practices. Generation and dissemination of knowledge that is relevant to the provision of healthcare for people and to the quality of the produced services. Utilization of mistakes and successes as subsidies to improve performance. Facilitation of access to information and a communication policy that promotes communication channels between professionals and services of the healthcare network. Development of clinical audit in the perspective of a problematizing learning.	9.83	0.41

Principles	Descriptors	M	SD
1. Focus on health needs and comprehensive care	The health needs of people and groups are complex, historically constructed phenomena that encompass the biological, psychosocial and cultural dimensions. Comprehensiveness of care as the guide to the organization of healthcare.	10.00	0.00
2. Quality and safety in healthcare	The obtention of maximum benefit by means of the continuous improvement in care quality and safety occurs by reducing the risk inherent in the care process for all the individuals involved, reducing damage to the lowest possible level, reducing the variability of clinical decisions according to the best evidences, and increasing safety.	9.71	0.49
3. Articulation and legitimation of different health practices and types of knowledge to face health problems	The development of care plans focuses on health needs and on multiprofessional teamwork with an interdisciplinary approach, compatible with the complex nature of the problems. The dialog between different healthcare practices and types of knowledge and the legitimation of user’s and family’s values and preferences aim to increase the effectiveness of healthcare. The sharing of teaching and service perspectives contributes to the education and qualification of health professionals in the work context.	9.43	0.79
4. Power sharing and co-accountability among managers, health professionals and citizens in healthcare production	The decision-making process in care networks with the participation of the services/professionals involved and the managerial mechanisms promote co-accountability and articulation among different environments and levels of care. The consensual definition of the responsibility of each point of the healthcare network takes into account: the promotion of comprehensive care targeted at collective interests; the integration of information and communication systems for shared decision-making; the establishment of articulated processes of cooperation among actors and institutions involved; incentive to participation and stimulation of professionals’ autonomy and creativity in the collective construction of care plans; teamwork, respecting different types of knowledge and potentialities; and responsibility for care shared among professionals, patients, families, community and managers.	9.29	1.25
5. Education of people and organizations	Educational practices view the individual sociocultural context and the service’s, institution’s or network’s context that are present in learning as knowledge construction. Health problems and challenges trigger learning, which takes into account the individuals’ previous knowledge, values, desires and interests. The reflective dialog between clinical management actions and the information about the reality enables to understand that practices can be reviewed in light of new information. Organizational education is seen as an articulated, upward and downward process involving all the spheres of work. The culture of permanent education and continuous assessment within the daily routine of work reorients health practices under the perspective of an organization that transforms itself. The utilization of mistakes and successes as subsidies to improve performance includes clinical audit, which assumes a perspective of problematizing and educational learning. The generation and dissemination of knowledge that is relevant to health production value the innovation of products and processes in healthcare, aiming to amplify the access to innovations.	9.00	0.82
6. Focus on outcomes that add value to health and life	The employment of standards to improve the efficiency and effectiveness of care by means of the use of outcome indicators targeted at the promotion of healthy lifestyles aims to reduce the use of unnecessary resources and to produce users’ health and autonomy.	9.00	1.15
7. Transparency and accountability regarding collective interests	Transparency in information and communication with people, populations, the media and society is present in decision-making and in the accounting of services and institutions involved in the healthcare network. Accountability for collective interests is expressed in the commitment to the health system’s guidelines, respecting the diversity of perspectives and the promotion of social control.	8.86	1.46

Fragmented systems	Integrated systems
Hierarchical organization of services	Networked organization referring to one health territory
Verticalized management focusing on command-control	Systemic, shared and co-responsible management
Financing according to procedures	Financing according to outcomes
Fragmented, discontinuous care targeted at diseases and centered on professional assistance	Comprehensive care targeted at health needs and centered on multiprofessional assistance
Irregular safety and quality	Safety and quality standards
Fragmented information	Integrated information

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[1] Collaborations

RQ Padilha, R Gomes, VV Lima, E Soeiro, JM Oliveira, LMC Schiesari, SF Silva and MS Oliveira were equally responsible for all the stages of the preparation of this article.