Hospital Performance in Brazil

The Search for Excellence

Gerard M. La Forgia, Bernard F. Couttolenc

• Publisher: World Bank Publications
• Year: 2008
• eBook ISBN: 9780821373590
• Edition: 0
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Hospitals are a critical component of the health care provided to many Brazilians. Hospitals--which absorb nearly 70 percent of public spending on health--are also a critical component of the government's budget, and are thus at the forefront of policy discussions. Why hospitals are important in Brazil is easy to understand. What makes hospitals deliver quality care efficiently--or not--is much harder to grasp. Drawing on an eclectic array of research and evaluative studies selected from a mix of sources, 'Hospital Performance in Brazil: The Search for Excellence' analyzes Brazilian hospital performance along several policy dimensions, including resource allocation and use, payment mechanisms, organizational and governance arrangements, management practices, and regulation and quality. Although a few Brazilian hospitals are world-class centers of excellence, many hospitals, including those who serve Brazil's poorest people, are low performers. Yet the Brazilian hospital system is both dynamic and pluralistic, and herein lies is strength. As is shown throughout the book, the foundations for change--approaches, ideas, innovations, and initiatives for addressing the shortcoming of underperforming facilities--are already present throughout the country's hospital system. Building on these strengths, the authors propose a policy- and practice-based hospital reform agenda that should assist policy makers and practitioners in their "search for excellence".

Table of contents

• Contents
• Foreword
• Acknowledgments
• About the Authors
• Policy Summary
• Acronyms and Abbreviations
• 1 Introduction
• 2 The Brazilian Hospital Sector: Structure, Financing, Spending, and Outcomes
• 3 Comparative Analysis of Costs and Efficiency
• 4 Hospital Payment Mechanisms and Contracting Arrangements
• 5 Organizational Arrangements and Performance of Brazilian Hospitals
• 6 Inside the Black Box: Linking Organizational Arrangements, Managerial Behaviors, and Performance in Public and Private Hospitals
• 7 Quality of Care: Still the Forgotten Component?
• 8 Quality Assessment and Improvement
• 9 Conclusions and Recommendations
• Bibliography
• Index
• Figure 1.1 Conceptual Framework for Hospital Performance
• Figure 2.1 Main Players and Fund Flows in the Brazilian Hospital Sector
• Figure 2.2 Distribution of National Health Expenditure, by Source, 2004
• Figure 2.3 Trends in SUS Financing, by Source, 1985–2004
• Figure 2.4 Payment and Transfer Flows for SUS Hospitals
• Figure 2.5 Hospitals, by Size and Ownership, 2002
• Figure 2.6 Long-Term Trends in Bed Supply, 1976–2002
• Figure 2.7 Privately Financed and SUS-Financed Patients, 2002
• Figure 2.8 Inpatient Care, by Clientele and Hospital Ownership, 2000–3
• Figure 2.9 Sources of Hospital Care Financing, 2002
• Figure 2.10 Hospital Spending, by Facility Ownership, 2002
• Figure 2.11 Hospital Spending, by Line Item, 2002
• Figure 2.12 SUS Hospital Spending, by Type of Care, 2002
• Figure 2B.1 Total Hospital Costs, United States, by Type of Expense, Fiscal 2003
• Figure 3.1 Distribution of Cases and Costs, by Case-Mix Index Range, 2001
• Figure 3.2 Distribution of Procedures, by Cost Intervals, 2001
• Figure 3.3 Costs by Hospital Type, Unadjusted and Adjusted for Case Mix, 2001
• Figure 3.4 Main Sources of Variation in Hospital Costs, 2001
• Figure 3.5 Coefficient of Variation for Surgical and Clinical Cases, 2001
• Figure 3.6 Composition of Procedure Costs, by AIH Category, 2001
• Figure 3.7 Distribution of Sample Hospitals, by Size and Ownership, 2002
• Figure 3.8 Technological Complexity, by Ownership, 2002
• Figure 3.9 Hospital Admissions, by Clientele, 2002
• Figure 3.10 Total Efficiency Scores, by Hospital Size, 2002
• Figure 3.11 Efficiency Scores, by Hospital Ownership, 2002
• Figure 3.12 Efficiency Scores, by Technological Complexity, 2002
• Figure 3.13 Efficiency Scores, by Teaching Status, 2002
• Figure 3.14 Bed Turnover Rate, 2002
• Figure 3.15 Mean Occupancy Rate for SUS Acute Care Hospitals, by Ownership, 2002
• Figure 3.16 ALOS for SUS Acute Care Hospitals, by Ownership, 2002
• Figure 3.17 Ratio and Composition of Personnel per Bed, 2002
• Figure 3.18 Total Personnel per Occupied Bed Ratio, 2002
• Figure 3.19 Surgical Patients per Operating Room per Year Ratio, 2002
• Figure 3.20 Technological Complexity per Bed Ratio, by Ownership, 2002
• Figure 3.21 Quality and Efficiency in Brazilian Hospitals, 2002
• Figure 3.22 Proportion of Inpatient Conditions Sensitive to Ambulatory Care, 2002
• Figure 3D.1 Relation Between Different Types of Efficiency
• Figure 3D.2 Technical and Allocative Efficiencies
• Figure 4.1 Hospital Funding, by Payment Mechanism, 2002
• Figure 4.2 Mean Ratio, SUS Schedule/Cost, by Procedure Complexity, 2002
• Figure 4.3 Total Efficiency Scores, by PPM, 2002
• Figure 4E.1 DRG Hierarchical Structure and Classification Criteria
• Figure 5.1 Hierarchy and Flexibility Scores for Organizational Structures, Alternative and Traditional Hospitals, 2000
• Figure 5.2 Percent of Full-Time and Volunteer Managing Executives of Nonprofit Hospitals, by Facility Category, 2000
• Figure 5.3 Percent Change in Selected Mortality Rates, Alternative and Traditional Hospitals, 1998–2003
• Figure 5.4 Percent Change in Selected Efficiency Indicators, Alternative and Traditional Hospitals, 1998–2003
• Figure 5C.1 Adjusted Costs Based on AIH Values, 2003
• Figure 5C.2 AIH Values, by Hospital Type, 2003
• Figure 6.1 Strategic and Normative Scores for Alternative and Traditional Hospital Behaviors, 2000
• Figure 6.2 Correlation between Flexibility and Strategic Scores, Alternative and Traditional Facilities, 2000
• Figure 6.3 Delays in Purchasing Supplies and Services, as Reported by Public Hospital Managers, by Subnational Level, 2003
• Figure 6.4 Principal Personnel Problems Identified by Managers, State and Municipal Hospitals, 2003
• Figure 6.5 Financial Information at Health Facilities, 2003
• Figure 6.6 Management Development Scores of Nonprofit Hospitals, by Category, 2001
• Figure 7.1 PNASS Facility Assessment Scores, 2005–6
• Figure 7.2 Hospital Infection Control, by Hospital Complexity
• Figure 8.1 Building Blocks for a National System of Quality Assessment, Management, and Improvement
• Table 2.1 Demographic and Health Trends
• Table 2.2 Financial and Economic Costs Related to the NCD Burden of Disease, 2005–9
• Table 2.3 International Comparison of Health Expenditure, 2002
• Table 2.4 International Comparison of Health Spending and Outcomes, 2002
• Table 2.5 Hospital Ownership, 2002
• Table 2.6 Disparities in Health Indicators in the Municipality of São Paulo, 2002–3
• Table 2.7 SUS Hospital Expenditure, by Care Level, 2002
• Table 2.8 Brazilian and International Patterns of Hospital Resource Allocation, 2000–2
• Table 2B.1 Health Facilities, by Region
• Table 2B.2 Geographic Distribution of Hospital Infrastructure
• Table 2B.3 Regional Variation in Socioeconomic Indicators, 1998–2002
• Table 2B.4 Hospital Financing, by Source, 2002
• Table 2B.5 Hospital Expenditure, by Financing Source, 2002
• Table 2B.6 SUS Expenditure, by Facility Ownership, 2002
• Table 3.1 Total and Intrahospital Cost Variation and Ranges for Procedures with Low and High CVs, Unadjusted for CMI, 2001
• Table 3.2 Composition of Hospital Costs, by Ownership and Line Item, 2002
• Table 3.3 Mean Costs in the Private Sector, 2002–4
• Table 3.4 Summary of DEA Results
• Table 3.5 Target Reduction in Resource Use, by Hospital Ownership, 2002
• Table 3.6 Equipment Density, Brazil and OECD Countries, 2002
• Table 3.7 Supply of Imaging Equipment in Relation to Need, by Region, 2002
• Table 3.8 Summary of Benchmark Indicators, by Total Efficiency Level
• Table 3.9 Tobit Regression Results, by Total Efficiency Scores
• Table 3.10 Coronary Bypass Surgery, Brazil, 1995
• Table 3B.1 Comparison of the De Matos (2002) Sample and the AIH Database
• Table 3B.2 TOBIT Regression of Total Hospital Inefficiency, Using Governance Model 2
• Table 4.1 Main Features of Hospital Payment Mechanisms Used in Brazil
• Table 4.2 Efficiency and Productivity Indicators, by Payment Mechanism
• Table 4.3 Average Cost of Typical Procedures, by PPM Group, 2001
• Table 4.4 Quality, Payment Mechanism, and Ownership, 2002
• Table 4.5 Performance Indicators Linked to the Variable Financing Component of the OSS Global Budget, São Paulo State, 2002–4
• Table 4.6 Comparison of Summary Features of the OSS Contract with the Draft Contract between the SUS and Teaching Hospitals
• Table 4E.1 Comparison of the AIH and DRG Systems
• Table 5.1 Organizational Arrangements in Public and Private Hospitals in Brazil, 2005
• Table 5.2 Comparison of Components of Organizational Arrangements in Brazilian Public Hospitals
• Table 5.3 Public Hospitals: Patient Mix and Sources of Financing, by Organizational Arrangement, 2002
• Table 5.4 Private Hospitals: Patient Mix and Sources of Financing, by Organizational Arrangement and Ownership, 2002
• Table 5.5 Executives Responsible for Nonprofit Hospital Management, by Hospital Size and Type, 2002
• Table 5.6 Nonprofit Hospital Executives Reporting Decision-Making Autonomy, by Function, Hospital Size, and Affiliation, 2002
• Table 5.7 DEA Scores by Ownership and Organizational Arrangement, Hospitals with More Than 25 and More Than 50 Beds, 2002
• Table 5.8 Comparison of Selected Quality and Efficiency Indicators, Alternative and Traditional Facilities, 2003–4
• Table 5.9 Compliance with Production and Performance Targets Stipulated in OSS Management Contract, 2002 and 2004
• Table 5.10 Comparison of Selected Hospitals under State and Municipal Direct Management with OSS-Managed Facilities, 2003
• Table 5.11 Comparison of Selected Quality and Efficiency Indicators, Hospitals under OSS and Direct Administration Arrangements, São Paulo State, 2003
• Table 5C.1 Summary Input Indicators, Traditional and Alternative Hospitals, 2004
• Table 5C.2 Comparison of Selected Quality and Efficiency Indicators, Alternative and Traditional Teaching Hospitals, 2003
• Table 5D.1 Comparison of Selected Indicators, OSS and Direct Administration Hospitals, São Paulo State, 2003
• Table 6.1 Managerial Autonomy in Public Sector Organizational Arrangements
• Table 6.2 Municipal Hospital São José dos Campos: Comparison of Available Production, Efficiency, and Quality Indicators Before and After Conversion
• Table 6.3 Formal Management Positions in Private Nonprofit Hospitals, by Major Function and Hospital Category, 2001
• Table 6.4 Formal Managerial Instruments and Practices in Nonprofit Hospitals, by Category, 2002
• Table 7.1 Significant Developments in Brazilian Medical Research, 2000–05
• Table 7.2 Physical Conditions in São Paulo Hospitals, by Ownership, 2003
• Table 7.3 Surgical Theaters with Minimum Required Equipment in São Paulo State, by Ownership, 2003
• Table 7.4 Equipment in Intensive Care Units in São Paulo State, by Ownership, 2003
• Table 7.5 Adequacy of Record Keeping in Hospitals in São Paulo State, by Ownership, 2003
• Table 7.6 Qualification of SUS Hospitals in a Brazilian State for ONA Level 1 Accreditation, 2002
• Table 7.7 Disciplinary Actions against Physicians in Brazil and the United States, 2001–5
• Table 7.8 Presence of Standardized Practice Norms or Treatment Protocols, Maternity Services in São Paulo Hospitals, by Ownership, 1997–98
• Table 7.9 HI Incidence in Adult ICUs, Brazil (excluding São Paulo), 2001–3
• Table 7.10 Existence and Functioning of Mandatory Hospital Committees, São Paulo State, 2003
• Table 8.1 Comparison of the Three Main Hospital Accreditation Systems
• Table 8.2 Number of Accredited Hospitals, by Type and Location, 2003
• Table 8.3 Costs and Investments Involved in Achieving ONA Level 1, 2002–4
• Table 8.4 Hospital Management Tools Used to Gain Accreditation, with Effectiveness Ratings, 2002–4
• Table 8.5 Efficiency and Quality in Hospitals with and without the CQH Seal of Quality, Selected Indicators, 1999–2003
• Table 8.6 PGQ Results at Santa Casa Hospital
• Table 8.7 Minas Gerais State: Spending on Admissions for Conditions Treatable in Ambulatory Care, by Hospital Size, 2002
• Box 2.1 A Brief History of Hospitals in Brazil
• Box 3.1 Types of Efficiency
• Box 3.2 Hospital Cost Structures in Brazil and Canada
• Box 3.3 Advantages and Limitations of Data Envelopment Analysis
• Box 3.4 International Experience in Health System Evaluation and Benchmarking
• Box 3.5 Making Rational Hospital Investment Decisions
• Box 3D.1 Measuring Hospital Complexity, Case Mix, and Quality from a Facility Survey
• Box 4.1 The AIH and the DRG: Similarities and Differences
• Box 4.2 Two Case Studies: Outsourcing Medical Care in the SUS
• Box 4E.1 Steps in Designing a DRG System
• Box 5.1 Achieving Labor Flexibility within Public Direct Administration: The Pro-Heart Foundation
• Box 5.2 Major Characteristics of Hospitals under Health Social Organization (OSS) Arrangements, São Paulo State, 2004
• Box 5.3 Governance and Management for Hospitals
• Box 5.4 Toward Greater Independence of Public Hospitals: Lessons from Europe
• Box 5.5 Managerial Modernization of Nonprofit Hospitals: Lessons from the United States
• Box 6.1 Organizational Forms and Health Worker Behaviors
• Box 6.2 Characteristics of a Well-Run Planning and Budgeting System
• Box 6.3 Managers’ Assessment of Managerial Processes and Practices in Hospitals under Direct Administration and OSS Arrangements, São Paulo State, 2003
• Box 6.4 The Politics of OS Implementation in the Health Sector
• Box 6.5 Hospital Conversion in Brazil: Legal Constraints and Opportunities
• Box 7.1 Major Dimensions of Quality Health Care
• Box 7.2 What Is Happening to the Quality of Medical Education in Brazil?
• Box 7.3 Problems with Quality and Possible Causes: Insights from a Literature Review
• Box 7.4 Bad Processes as a First-Order Problem: Interaction between Structure and Practice in Neonatal Wards
• Box 8.1 Accreditation, Licensure, and Certification
• Box 8.2 Governance Arrangements in the ONA
• Box 8.3 Benchmarking
• Box 8.4 What Is an Organized Regional Network?
• Box 9.1 Building on International Innovations and Experience
• Box 9.2 Recentralization in Scandinavia? Achieving Coordination across Political Jurisdictions