8 perguntas da administração ao corpo clínico: o que o gestor hospitalar sempre quis saber e teve coragem de perguntar

Rodrigo Pinheiro Machado

Veja o vídeo desta palestra em nosso canal no YouTube

“Reunião com a diretoria administrativa? Que chatice! Sugerir medicamentos, equipamentos, novas técnicas? Não adianta, o gestor vai dizer que não tem dinheiro. Prefiro chegar na hora da minha cirurgia, operar e ir embora.” Se você já disse ou ouviu de colegas essas frases, está vivendo uma era de distância entre a gestão administrativa e o corpo clínico dos hospitais que precisa acabar, segundo o consultor e gestor Rodrigo Pinheiro Machado, porque essa distância “vai doer no bolso de todo mundo”. Com 20 anos atuando na área de saúde, na gestão de 10 hospitais, e atualmente realizando consultoria para 15 instituições de saúde, incluindo cinco hospitais, ele afirma que precisamos vencer essa distância o quanto antes: “Não conseguimos juntar essas duas pontas (gestão administrativa e corpo clínico) para conversar porque, quando começamos a falar sobre melhoria de procedimentos, quem sabe experimentar um medicamento novo, vira discussão e acaba a reunião. De um lado se quer defender o custo, a realidade, o financeiro, a sobrevivência do hospital e do outro se ouve: ‘mas eu sempre usei esse remédio, não quero usar outra técnica, não quero mudar esse protocolo, é assim há 20 anos…’ Mas precisamos discutir o novo modelo de negócio que já chegou ao Brasil”.

Baseados no que Machado trouxe em sua palestra no AnestEdu, trazemos aqui 8 perguntas da gestão hospitalar para o corpo clínico.

Veja também: Afinal, o que querem os gestores hospitalares? Engajamento da equipe médica para oferecer valor em saúde ao paciente

Pergunta 1: Você sabe de onde vem a receita do hospital em que você trabalha?

Uma das perguntas que Rodrigo Machado fez aos médicos anestesistas, cirurgiões e outros profissionais médicos que estavam presentes à conferência “O que o Gestor de Saúde Espera de uma Empresa de Anestesiologia em sua Instituição de Saúde?”, no 8º AnestEdu, foi: Vocês sabem a origem do faturamento das contas hospitalares? Segundo os dados de 2016 do Sistema de Indicadores Hospitalares da Associação Nacional de Hospitais Privados (Anahp): Distribuição de Receita por Natureza (%), a resposta é:

  • Diárias e taxas de permanência dos pacientes: 19,4%
  • Medicamentos: 22,8%
  • Materiais: 20,1%
  • Órteses, Próteses e Materiais Especiais: 8,2%
  • Gases medicinais: 2,3%
  • SADT: 12,9%
  • Outras receitas de serviços: 2,6%
  • Doações: 0%
  • Outras receitas operacionais: 11,7%

É importante que o corpo clínico saiba disso? Machado acredita que é muito importante que o corpo clínico não apenas saiba disso, mas participe das discussões sobre isso com a gestão.

Pergunta 2: Você está preparado para a mudança da forma de remuneração das operadoras de planos de saúde para com as instituições de saúde, seus profissionais médicos e outros, que já está ocorrendo?

Diante da maior fonte de receita dos hospitais privados detectada pela Anahp – medicamentos (22,8%) – Rodrigo Machado questionou: “o negócio do hospital é vender remédio para ganhar dinheiro e pagar a conta?” Segundo ele, atualmente, os hospitais brasileiros são farmácias gigantescas porque esse foi o modelo que se estabeleceu no Brasil, modelo que está com os dias contados. Para Machado, é errado um hospital abrir mão da remuneração do valor da diária, sua atividade fim, para sobreviver somente da venda de medicamentos e material médico. Se os valores das diárias são pequenos é, segundo disse, outra discussão que vem de longe e não há como resgatar agora. Agora, o que se vai discutir é a mudança do modelo de gestão, pois não é novidade que os hospitais do país, de forma geral, estão mal geridos, com prejuízo, e correm o risco de fechar ou ser adquiridos por um comprador expressivo de mercado, que pode vir a substituir as equipes atuais desses hospitais por pessoal próprio. “A empresa hospital sempre vai continuar existindo, mas precisamos saber se estaremos dentro. Se fecha o hospital, fecha para o médico, para o gestor, para a família que dependeu daquele empreendimento a vida toda”, alertou.

Segundo ele, a tão falada nova forma de compra dos serviços hospitalares, que inclui os honorários médicos – um novo modelo de remuneração por performance –, já está sendo negociada e em teste em cidades de referência no país, e vem exatamente para impedir que a medicina compradora de serviços quebre. “Há 18 hospitais em teste com o novo modelo de pagamento, incluindo o honorário médico, no Brasil”, afirmou.

Veja também: Sistema de saúde seguirá existindo, mas você estará dentro?

Pergunta 3: Você sabe quem paga a conta das cirurgias que você realiza?

“Tudo que estamos mandando para dentro do centro cirúrgico está sendo cobrado na conta do paciente? Não vemos isso nas contas hospitalares”, disse Rodrigo Machado e citou um exemplo em que foram gastos quase R$ 600 mil em compra de órtese e prótese usadas no paciente, mas que não foram cobrados na conta do hospital. “Alguém já apresentou a vocês um indicador para demonstrar resultados positivos ou negativos do centro cirúrgico? Ou um ticket médio do custo de uma cirurgia, sugerindo melhorias com a equipe, em conjunto?”, perguntou.

E há mais perguntas incluídas nessa: Há muita tecnologia embarcada em um hospital, em um centro cirúrgico? Quanto se gasta nessa tecnologia e quanto se usa dela? Paga-se o preço de muita nova tecnologia, mas ela é efetivamente usada? O quanto ela ajuda na gestão do hospital?

Pergunta 4: Você preenche os documentos imprescindíveis?

Rodrigo Machado disse que no centro cirúrgico trabalham pessoas altamente qualificadas, com preparo específico – desde o pessoal da limpeza, enfermagem, instrumentação até médicos cirurgiões e médicos anestesistas – com as quais a gestão precisa contar para a realização de determinadas tarefas que não dizem respeito somente ao trabalho médico. “Há muitos bons resultados, pacientes bem tratados e saindo bem do hospital, famílias agradecendo. Entretanto, quando me refiro a tarefas, trazendo essa palavra à ótica da gestão hospitalar, em função das regras, normas e leis imputadas me refiro a todo o necessário para fazer com o que o hospital fature. São os documentos obrigatórios que muitas vezes são tratados – ou infelizmente destratados – como sem importância: prescrições cirúrgicas e evoluções anestésicas que descem com faturamento sem carimbo e assinatura, etc.”

“O paciente foi tratado, foi para UTI, foi para o quarto, teve alta, pronto. Próximo! Para quem continua a atividade na área administrativa, que depende da ‘chatice’ dos documentos, não. O modelo foi feito dessa forma, e o Brasil aceitou.”

Veja também: Como levar seu hospital à excelência: a importância das habilidades não técnicas

Pergunta 5: Você sabe quais documentos obrigatórios precisa preencher para que seu hospital fature?

Segundo Rodrigo Machado, somente com o preenchimento correto de todos os documentos, como descrição cirúrgica, anestésica, saída de sala, evolução da Repai, prescrição médica, evolução da enfermagem e laudos é possível fazer o faturamento do hospital.

A Anahp divulgou que, a partir do preenchimento correto desses documentos, em 2016 foi possível o faturamento de R$ 28,3 bilhões em 80 hospitais: “São esses papeizinhos chatos de escrever que transformam o numerário de faturamento do grupo das instituições”, disse Machado.

Veja os registros obrigatórios e legais da administração hospitalar, com os comentários (entre aspas) de Machado:

  • Autorização pelo convênio do Procedimento a ser realizado
  • Contrato de Internação com a Instituição de Saúde. “Caso o seu convênio não pague essa conta, ela lhe será encaminhada.”
  • Consentimento Informado assinado pelo paciente para a Cirurgia. “A cirurgia tem riscos e esse é um documento, por exemplo, que nos foi imputado pela qualidade. O volume de demandas jurídicas contra hospitais aumentou 600% nos últimos cinco anos.”
  • Identificação Individual para Segurança do Paciente. “Os índices de erro de lateralidade têm preocupado. O Ministério da Saúde lançou, há cerca de quatro anos, e agora começou a cobrar dos hospitais, os protocolos de segurança do paciente. É uma obrigação nossa, mas estamos preparados?”
  • Resultados de Exames Complementares Anteriores. “Há laudos e exames que desaparecem quando o paciente tem alta.”
  • Avaliação Cardiológica
  • Descrição Cirúrgica
  • Descrição Anestésica
  • Saída de Sala
  • Evolução Recuperação Pós-anestésica. “Já vi ocorrer glosas de convênios porque não havia evolução.”
  • Prescrição Médica
  • Evolução da Enfermagem
  • Laudos e Exames realizados
  • Sumário de Alta Hospitalar. “Há pacientes que estão de alta ‘só que não’. Falta liberar. A equipe não sabe se dá alimento para ele ou não porque faltou o médico passar com sua alta, carimbar e assinar.”

Pergunta 6: Com que frequência você vai a reuniões visando reduzir custos, investir em novas tecnologias, à definição de novos protocolos, investir em segurança do paciente e a discussões sobre o comportamento dos indicadores do centro cirúrgico?

Rodrigo Machado contou que em reuniões de Comissão de Controle de Infecção Hospitalar (CCIH) que presenciou já ouviu de médicos “que chatice!”: “Muitos médicos não vão. Estão lá as enfermeiras, os residentes e a gestão, e a reunião segue.”

Pergunta 7: Quanto você é comprometido com acreditação hospitalar e intercorrências e não conformidades?

Machado questionou se os hospitais têm se preocupado o suficiente com esses assuntos e questionou ainda instituições que não se submeterem a acreditações ou certificações por serem processos caros: “São caros, mas mais caro será ficar sem o hospital”.

Também alertou quanto à falta de implementação de processos de qualidade em algumas instituições pelo medo de serem obrigadas a registrar eventos adversos, o que reflete em estatísticas falhas.

Veja também: Acreditação hospitalar é mesmo importante? Só se tiver qualidade e segurança assistencial e fornecimento e captação de dados

Pergunta 8: Você agrega valor ao seu negócio? Como?

Machado sugeriu que os médicos, que vivem a realidade e o dia a dia do centro cirúrgico e do cuidado do paciente, levem à administração e à gestão sugestões e informações sobre equipamentos, materiais, medicamentos e técnicas na busca pelo melhor resultado. Segundo ele, a principal resposta que ouve quando diz isso é que não adianta porque os gestores sempre dizem que não há dinheiro, mas que quando a sugestão e a informação são baseadas em dados e valor agregado, a resposta pode ser diferente. Além disso, também se podem sugerir formas de financiamento.

Seriam muito bem-vindas também sugestões de melhorias na padronização de material e medicamento, além da participação do corpo clínico, por exemplo, em reuniões para discussão de novos contratos para compradores dos seus serviços e propostas para buscar a redução de glosas: “Será que quando o hospital é glosado, o serviço que originou a glosa é chamado a prestar conta?”

 

E nós perguntamos: Você que faz parte do corpo clínico ou de outra área de um hospital ou instituição de saúde sugeriria outras perguntas? Faria alguma pergunta aos gestores? Comente!

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  87. This is getting a bit more subjective, but I much prefer the Zune Marketplace. The interface is colorful, has more flair, and some cool features like ‘Mixview’ that let you quickly see related albums, songs, or other users related to what you’re listening to. Clicking on one of those will center on that item, and another set of “neighbors” will come into view, allowing you to navigate around exploring by similar artists, songs, or users. Speaking of users, the Zune “Social” is also great fun, letting you find others with shared tastes and becoming friends with them. You then can listen to a playlist created based on an amalgamation of what all your friends are listening to, which is also enjoyable. Those concerned with privacy will be relieved to know you can prevent the public from seeing your personal listening habits if you so choose.

  88. The new Zune browser is surprisingly good, but not as good as the iPod’s. It works well, but isn’t as fast as Safari, and has a clunkier interface. If you occasionally plan on using the web browser that’s not an issue, but if you’re planning to browse the web alot from your PMP then the iPod’s larger screen and better browser may be important.

  89. Hands down, Apple’s app store wins by a mile. It’s a huge selection of all sorts of apps vs a rather sad selection of a handful for Zune. Microsoft has plans, especially in the realm of games, but I’m not sure I’d want to bet on the future if this aspect is important to you. The iPod is a much better choice in that case.

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  91. This is getting a bit more subjective, but I much prefer the Zune Marketplace. The interface is colorful, has more flair, and some cool features like ‘Mixview’ that let you quickly see related albums, songs, or other users related to what you’re listening to. Clicking on one of those will center on that item, and another set of “neighbors” will come into view, allowing you to navigate around exploring by similar artists, songs, or users. Speaking of users, the Zune “Social” is also great fun, letting you find others with shared tastes and becoming friends with them. You then can listen to a playlist created based on an amalgamation of what all your friends are listening to, which is also enjoyable. Those concerned with privacy will be relieved to know you can prevent the public from seeing your personal listening habits if you so choose.

  92. I’ll gear this review to 2 types of people: current Zune owners who are considering an upgrade, and people trying to decide between a Zune and an iPod. (There are other players worth considering out there, like the Sony Walkman X, but I hope this gives you enough info to make an informed decision of the Zune vs players other than the iPod line as well.)

  93. The Zune concentrates on being a Portable Media Player. Not a web browser. Not a game machine. Maybe in the future it’ll do even better in those areas, but for now it’s a fantastic way to organize and listen to your music and videos, and is without peer in that regard. The iPod’s strengths are its web browsing and apps. If those sound more compelling, perhaps it is your best choice.

  94. Apple now has Rhapsody as an app, which is a great start, but it is currently hampered by the inability to store locally on your iPod, and has a dismal 64kbps bit rate. If this changes, then it will somewhat negate this advantage for the Zune, but the 10 songs per month will still be a big plus in Zune Pass’ favor.

  95. The Zune concentrates on being a Portable Media Player. Not a web browser. Not a game machine. Maybe in the future it’ll do even better in those areas, but for now it’s a fantastic way to organize and listen to your music and videos, and is without peer in that regard. The iPod’s strengths are its web browsing and apps. If those sound more compelling, perhaps it is your best choice.

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