Démarche estratégica em unidade materno infantil hospitalar Strategic Démarche in a mother and child hospital unit

PROCEDIMENTOS METODOLÓGICOS: Foi realizada aplicação adaptada do enfoque na unidade materno-infantil de hospital público estadual, localizado no município da Serra, ES, como análise da gestão hospitalar, com envolvimento indireto dos atores institucionais que se constituíram nos informantes-chave no período de abril a julho de 2006. Além de reuniões com atores-chave, os dados foram obtidos nas fontes: livros de registros de internações do centro obstétrico, da maternidade e do berçário, faturamento do hospital, relatório estatísitico dos resultados perinatais da unidade materno infantil; livros de atendimento do ambulatório de aleitamento materno, considerando o ano de 2005.


INTRODUCTION
The growing specialization of knowledge in health, the concentration of activities and technologies, the reduction of resources that strains equity in the public services and the need for permanent education as central to professional competence require evaluation and strategic planning of public hospitals.The changes in the paradigms of medicine,\ of the public services and of professional health education, particularly medical education, lead to a crises in the identity of hospital organizations that weakens individuals' bonds to the organization. 3 model of negotiated management should explore synergies and partnerships and create sites for collective refl ection and distribution of responsibilities.The strategic démarche approach strives to articulate rationality in attending to the populations' necessities with the broad participation of actors.It privileges change and learning as intrinsic phenomena that have a permanent character within the organization (Artmann & Rivera 1 2003).
This approach seeks to defi ne the hospitals' mission, having as a reference the demographic/organizational and epidemiological context of the hospital organization.It is based on the adaptation of Porter's 5 (1982) business approach to the health services' public sector.The strategic démarche is based on elements of micro economy, of the fi eld of strategy and policy and the area of organizational development and, furthermore, it involves a cultural analysis of the institution.In addition, it proposes to redesign the institutional mission and seeks to attain the insertion of the hospital, in a coordinated manner, within the network of health services (Artmann & Rivera 1 2003).
The method was originally designed for regional hospitals, considering the French health system in a context of contention of public resources.In Brazil, it has been applied in some experiences of hospital management and insertion of hospitals in the network as can be verifi ed in Artmann & Rivera 1 2003; Artmann 2 2002; Rivera 6 2003, as well as other documents by Lopes 1997; a Souza 1997; b Favacho 2001; c and Artmann 2002. d The potential of the method must be stressed, particularly for hospital units that, due to their strategic location, should attend to a regional demand.The state hospital chosen as the site of this study has this characteristic.
The rate of annual growth of the municipality where this hospital is located is estimated in 3.5% (Ministry of Health 2007).e Due to the high migratory fl ux, the municipality's population rate is above the national rate 1.9 (Ministry of Health 2007), f resulting in an inordinate growth of the region and serious social problems articulated to health problems.These, in turn, interfere in the services network, which does not have the capacity to include all citizens.Within this context, this hospital, the only public institution in the municipality which is a reference for medium and high complexity care, becomes overloaded.The peculiarity of having been built as a temporary solution and of having had its useful life extended, in a region characterized by high, inordinate population growth, indicates the necessity of a study to evaluate its organization and management.

Strategic approach
Cremadez and Grateau are responsible for idealizing the Strategic Démarche approach.
The theoretical premises of the strategic démarche consider the main characteristics of a professional organization, constituted as a conglomerate of highly specialized independent units in which work is coordinated by mutual adjustment and the techno structure has a low capacity of interfering in operational processes.Coordination is processual and organized according to results and management of the several service chiefs is carried out by the direction through indirect management (Mintzberg 4 2003).Therefore, the decision making practice of these organizations frequently does not possess a perspective takes into consideration the organization as a whole.Strategic management proposes to undo this dissociation between the strategic direction and the services at the end of the line in search of a coherent set of projects.Transparency, sharing information, reconstructing the different domains of activities exploring potential synergies, constructing a pedagogy of evaluation, introducing the rationale of opportunity costs and captivation of additional resources by means of projects are the instruments with which it intends to create a network of solidarity (Artmann & Rivera 1 2003).
The main objectives of the strategic démarche are: 1) to promote a link in a bond between strategic management and the centers of assistance; 2) defi ne the mission of the hospital according to criteria of opportunities; 3) transform the hospital in a locus of supply of integrated services which have as their principal effi cacy and efficiency; 4) make it possible to create a collective project by means of actor-services; and 5) promote a process of progressive cultural transformation (Rivera 6 1997).
The objective of this study was to describe the differentiated application of the strategic démarche approach, utilized as a method of management analysis and as a form of evaluation of a hospital unit.The major adaptation was the use of this approach to analyze hospital management, with the indirect involvement of seven participants considered institutional agents.The latter were constituted by physicians and nurses among others and acted as key -informants during the period from April to July 2006, considering the phases described below: Analysis of what exists: corresponds to the initial medical and administrative diagnosis, besides including a list of partners, competitors and the design of the network of care. 1 The administrative diagnosis focuses on information concerning physical structure, human resources, demand profi le, among others.The medical diagnosis comprehends the list of pathologies organized according to medical specialties and the technologies utilized by each specialty, in conformity with the complexity; the matrix of pathologies and technologies, and a list of the modalities of care.
The data necessary for analysis during this phase of the method were obtained by means of the letter of hospital services b , of the construction project for the new hospital, c that would substitute the old one and of the 2005 report on the perinatal outcomes of the mother and child unit of this institution.d The bases for the regionalization of the state e were consulted so that it would be possible to undertake a survey of the competitors/collaborators in function of the technologies and modes of attention indicated by the segments analyzed.This survey made it possible to compare the hospital's capacity to attend to demands with the potential competitor.
The selection of the mother and child unit to apply the strategic démarche was based on the following criteria: 1) its macro-regional importance in attending high risk pregnancies; 2) the need for a more methodic analysis so as to direct the future institutional mission, which at that moment did not include this sector in its expansion plans; 3) previous insertion of one of the members of the research group in the mother and child unit of the hospital, making more information on this sector available.
Segmentation: defi nition of the main groups of homogeneous activities, generally defi ned by specialty considering the categories pathology, technology, modes of attention and population, that allow for a strategic, multicriteria analysis which is representative of the institution.
The choice of segments was based on the pre-existing structural organization of the mother and child unit.The segments were defi ned using the following criteria: mode of attention, population and, specially, technology.
Analysis of the value of the segments: refers to the interest or level of relative priority that the segments would have for the specialties, in function of a general policy and expresses itself through the interest in allocating resources to them. 1 Makes it possible to analyze and to organize each segment hierarchically, by pondering multiple criteria.This analysis allows for a prospective vision of how each segment would behave in relation to each criterion.
The criteria utilized in analyzing each segment, were: growth potential; intensity of competition; entrance obstacles; synergies (at the level of shared competences and infra-structure); internal motivation; possibilities of external partnerships; regional potential; local potential; research and education potential; contribution towards the political project of the hospital; contribution towards the external image of the hospital and capacity to attract external resources.The defi nition of the relative weight of these criteria was obtained by distributing 100 points according to their relative importance to each segment.Afterwards, analysis was conducted and each segment was organized hierarchically, being attributed grades from 0 to 20 according to relative criteria, among which the current state and market perspectives were particularly stressed.The fi nal value of each segment was obtained by a score which was the result of the product of the relative weights multiplied by the grades.
Analysis of the competitive position: this is evaluated considering the degree of control over key factors of success, that correspond to the advantages of positive situations that are necessary in order to guarantee success in an activity. 1 The key factors determine the hospital's capacity to obtain better results on each of its segments and activities, that is, to satisfy the demands of the service in both quantity and quality. 3e hospital's mission, the real demand for attention and supply of services from the network were taken into consideration in the analysis of factors.It must also be observed that the competitor/ collaborator, a university hospital, was located outside the micro-region, but inside the macro-region.
In order to determine the strategic competitive position between two institutions and compare their performance in relation to the key factors of the segments afterwards, it was necessary to seek key informants that worked in the maternity and obstetric center of both hospitals.The technical performance and the process of attending high risk pregnant women were evaluated.
The defi nition of the relative weight over the competitive position was obtained by distributing 100 points for the relative importance of key factors.Afterwards, grades ranging from 0 to 20 were attributed to each factor in accordance to their degree of real control.Finally, by means of consensus established between the research group and the hospital's professional staff, the relative position, of the hospital and its competitors, was determined, by comparing the scores -the result of multiplying the relative weight by the grade of each segment.
Portfolio of activities: constituted by the value, competitive position and volume of production of the segments.It makes it possible to determine priorities and design general strategies such as growth, maintenance or decrease in the activities or the creation of a segment.These strategies were detailed in the plan of action.
The portfolio is the instrument which allows one to visualize the performance of the institution being analyzed immediately and makes it possible to have an idea about how it is fairing as a whole and its comparative value with respect to its competitors.
Obtaining data on production with respect to each segment initially required the defi nition of indicators that could represent them as such.Indicators were defi ned for production in 2005, the year before the period of analysis, by means of the books in which attention in the obstetric center and in the nursery were registered, as well as data concerning hospital invoices, and information registered by the professional responsible for data concerning production of the mother and child unit for the State Department of Health, as well as the agendas where consultations in the breastfeeding ambulatory were scheduled.However, information was dispersed and, sometimes incomplete in the registers, agendas and the patients' fi les, which made it necessary to estimate some of the data.
Plan of action: requires a continuous reappraisal geared towards increasing control of the Key Factors of Success, so as to improve the general strategic position. 1In the analysis of key factors of success, the grades were attributed in two moments: initially by the research team and, afterwards, these were confronted with the grades attributes by the hospital's professional staff.
Therefore, the plan of action resumed itself to a strategic design, based on the portfolio.
This study was approved by the Ethics in Research Committee of the Escola Nacional de Saúde Pública [National School of Public Health].After the research was approved by the institution where it was to be conducted and the Terms of Informed Consent were signed by the professionals who would participate, the method was applied, with some adaptations, based on the script by Artmann & Rivera 1 (2003).

RESULTS OF THE EVALUATION
Once the maternal and child unit was chosen as the target of the study, strategic analysis selected the following segments according to the criteria mode of attention and population: obstetric center, maternity ward, program of humanized care to the mother and newborn.The segments selected were: obstetric surgical center, neonatal intensive care unit and intermediary care unit.These were selected due to their differentiation and to their technological concentration.
The segments were analyzed according to the criteria mentioned above and the weight attributed to each criterion corresponded to its relative importance in terms of performance and institutional priorities.Greatest weight was attributed to the possibilities of external partnerships due to the fact that the hospital was situated in an industrial pole, which made the entry of fi nancial resources for projects in the fi eld of mother and child health viable.The smallest weights were attributed to the criteria intensity of competition, due to the fact that this was the only public hospital of reference in the micro region for high risk pregnancies, and to the criteria contribution to the general political project of the hospital, based on the fact that the expansion of the mother and child unit was not included, when the study took place, in the building project for the new hospital.
In the matrix of the analysis of the value of each segment (Table 1), by organizing them hierarchically, pondering the criteria and the relative notation, almost all the criteria of the segments neonatal intensive care unit and obstetric surgical center were valued.This result expresses the importance attributed to the technology and the need for the continuous investment in the development of advanced techniques in surgery, in technology for neonates and in the qualifi cation of professionals attending high risk pregnant women and newborns.The value attributed to the intermediary unit and to the Program of Humanized Care to Mothers and Newborns was low.If it was considered a differentiated segment of the neonatal intensive care unit, this analysis would have a separation bias naturally expected due to the segmentation that was different than that proposed in the organogram.The importance of the insertion of a service of medium complexity in a hospital unit revealed the need to review the value attributed to this segment.
The hospital being studied is a regional reference for high risk maternal and infant care.All the other units of the municipal and micro-regional network detain a great responsibility for antenatal care and for following up the child afterwards as well as for low risk birth assistance.Therefore, it was decided that the university hospital of the State capital would be considered as competitor since the latter was a benchmark in specialized care, despite the fact that it was not a part of the micro-regional health network.
Tables 2 and 3 show the results of the comparison between the segments taken into consideration in the two hospitals, both in terms of what was valued and of the grades received for key factors of success identifi ed in each of them.
Table 2 presents the segments identifi ed by technological differentiation and indicates that the university hospital presented a better competitive position than the study hospital in the three segments, particularly in the obstetric surgical center, in which there was a less competitive position.Despite the fact that the neonatal intensive care unit of the study hospital presented a lower competitive position than the university hospital, this difference was not very expressive.As to the intermediary unit, this difference was also not signifi cant.
The decision to consider the university hospital as a competitor/partner implied in a problem in terms of comparison, for it presented a strong penchant for teaching and research.Consequently, it presented advantages in terms of technological complexities and specialization in human resources.
Analysis of the competitive position of the segments guided by the criteria mode of attention and population (Table 3) indicated a better competitive position in the segments obstetric center and maternity ward in the university hospital.The program of humanized care conferred a competitive advantage to the study hospital.Thus, even though it had lower level of technological concentration, this hospital could stimulate the use of light technologies that could contribute towards the valorization of the humanization of care, such as, hospital treatment and support, a room for collecting and stocking human milk, immunization of newborns and puerperal women.The fact that this was the only hospital segment that was in a better relative position than its competitor/partner indicated the possibility of reinforcing humanization as a strategic factor of success in the different segments.This fact confers greater competitive advantage to the study institution, in an area such as maternal-infant care, in which humanization is a factor of differentiation.
Among the 33 key-factors of success identifi ed, only eight presented small differences in the grades.This difference could be related to changes in the interval of time of the process of attributing grades.The surgical center, for example, suffered a reduction of physical space and equipments, as well as the substitution of professionals, leading to the attribution of lower grades.
The organization of information so as to permit comparisons, allows for rectifi cations, validations, acquisition of additional information and consensus that constitute a clearer view of the potentialities of each hospital in terms of its response to health demands/necessities. a Therefore, despite the possible bias in the view of the different actors that generally evaluate  according to their position in the hospital, according to their own experiences and their professional specifi city, the method indicates that, because it is based on well defi ned criteria, it presents a good potential to express the analysis of reality.
In order to construct the portfolio, it was consensus that the last notation should be taken into consideration, due to the up-dating of information.
The portfolio allows one to visualize immediately the performance presented by the institution being analyzed, for the point of departure for its construction is the value, the competitive position and the volume of production of the segments.
Analysis of the portfolio (Figure ) indicated that the segments neonatal intensive care unit and intermediary unit are situated more to the right, refl ecting a weak strategic risk, although the lowest value attained is evidently the intermediary unit.The segments obstetric center and program for the humanization of care, although they did not present great strategic risk, would need to improve their competitive position.The surgical obstetric center and the maternity ward, despite being relatively well valued, presented the need for a strong investment in order to improve their strategic position.The low competitiveness of the maternity ward associated to its high volume of production would indicate a large number of procedures of lower complexity that could be directed towards other unities in the network.As an effect of this, this sector would win in terms of quality and competitiveness.The surgical center, that also presents less competitiveness, would need and should deserve more investments, both in terms of technology and in reinforcements as to professional competence.

FINAL CONSIDERATIONS
The elaboration of a plan of action depends on the capacity of collective mobilization articulated to the commitment of local directors in increasing the control of the key factors of success, with the objective of improving the general strategic position of the organization within the health network.
The results of the strategic démarche as a method of analysis of hospital management indicated subsidies for restructuring and redirecting the institutional mission, in particular in the mother and child unit.
This study made it possible to establish a detailed description both of the internal hospital environment (segmentation, value of the segments, information system) and the external environment (regional network, competitors/partners), indicating paths for the construction of a plan of action.
The strategies utilized to improve the competitive position seek to increase the value for the benefi ciary or involve less resources without diminishing the value of the service, as perceived by the benefi ciariy in terms of quality. 2 The strategy of diferentiation accentuates value, 2 therefore, the fact that humanization was the only segment in a better position in comparison to the competitor/partner leads to the consideration that investment in humanization of care would produce a dominant strategic advantage.
The competitive advantages of the study hospital with respect to the predominantly technological segments would be obtained by means of a technological increment, considering the concentration of equipment as a factor of scale economy, allied to costs strategy that reinforces the synergic potential.The control of operational costs of human resources would be attained with a greater investment in education and organization.
The scarcity of bed in the rear guard was evidenced as one of the critical points in obtaining strategic advantages.Besides the increase in rear guard beds, it is necessary, within a costs strategy, that the hospital institution maximizes its rate of occupancy, conferring privilege to specialized attention that are in conformity with its mission and the particularization of its structure.
The articulation with the network, in an effective system of reference and counter-reference is fundamental to this strategy and to the quality of attention.
The implementation of a standardized, functional system of information is an activity of operational support that is necessary for the accomplishment of the principal activities of the institution investigated.
Considering the low value attained by the intermediary unit, it is necessary to discuss differentiation strategies for the segment, principally because of the tension exercised by critical patients on the health system, whether this be related to the process of accreditation of beds and units, or to its utilization attending to the real necessities of the population.This analysis enlarges the importance of refl ection on the insertion, in a qualifi ed and strategic manner, of the units of intermediary care in intensive care in the process of assisting the critical patient.Public consultation concerning the National Policy of Care to the Critical Patient is essential for this discussion.a The defi nition of the institutional mission in focus as a specialties hospital or as a reference hospital for emergency care in the micro region is fundamental.
This study revealed itself as an interesting exercise due to the diversity of issues that emerged, whether these referred to the object of analysis or to the approach itself.The strategic démarche demands the articulation of actors involved in a collective project that considers the network of care integrating attention and management.The logic of implementation of this method, based on meetings of collegiates, is itself immersed in the objective of promoting a broad communication at the service of a cultural transformation, 2,6,7 This, in turn requires a historical time that presents variables such as greater political and administrative stability.In this study, it was not possible to analyze such a time framework, for it deals with a recent experience.However, the adaptation accomplished here presents some differentiating aspects.The fi rst of these refers to the application of this method, having as its point of departure a key informant inserted in the study group, a strategy which is very differentiated in relation to the original proposal, in which the involvement and direct participation of the actors in the process of (re)defi ning the hospital's mission is indispensable.In order to diminish a possible bias, the research group, besides using data from the hospital fi les, interviewed key professionals from the staff who expressed their perceptions concerning the analysis of value of the segments and the competitive position, both of the study hospital and the competitor/partner hospital.Thus it was possible to confront their opinions with the evaluation made by the research team.The second aspect was the fact that the approach was applied in one unit instead of in the entire hospital.The fl exibility which the method offers as an instrument of management made this type of adaptation possible.
The strategic démarche is an administrative tool that considers various dimensions of organizational and productivity analysis, allowing for the creation of channels of communiction between the strategic direction and the operational level.It makes it possible to share the future of the organization with the different actors involved in the process of production, including them in the process of formulating policies, in the work process and in the evaluation of the results of the organizational production.
The results of this study indicate the possibility of utilizing the strategic démarche, not only as a tool of hospital management, but also as an instrument in the diagnosis of the existing situation.
Its implementation should have as its outcome a plan of action so as to make the hospital more competitive and stimulate the defi nition of monitoring indicators and evaluation of activities.Competitivity is understood as a possibility of sharing and solidarity within a network in search of resources that cab satisfy the demands of the benefi ciaries.Strategic management stresses the principal of complementarity among different hospitals and all other units in the network, emphasizing the concentration of efforts in "making what one knows how to do best".In the same manner, the term competitor is conceived as a factor of "benchmarking" in search of better existent practices within the network.
The results presented indicate the potential of the method for problematizing the mission and for the analysis of hospital management strategies to improve the quality and competitiveness of the segments and for the greater insertion and integration in the network of services.

Figure .
Figure.Portfolio of the activities developed by segments at the mother and child unit of a public state hospital.Serra, Southeast Brazil, 2006.

Table 1 .
Value of the segments of a mother and child unit of a public state hospital, according to criteria and weight of the evaluation.Serra, Southeast Brazil, 2006.

Table 2 .
Competitive Position of the technological segments, in the mother and child unit of a public state hospital and of a university hospital, according to strategies of success.Serra, Southeast Brazil, 2006.

Table 3 .
Competitive position of all other segments, in the mother and child unit of a public state hospital and a university hospital according to strategic factors of success.Serra, Southeast Brazil, 2006.