HEALTH GROUPING, EEIGProjecto da Corrida Consulting, Ltd consensual que o futuro da sade passa pelos Registos Mdicos Electrnicos (RME) ou Registos de Sade Electrnicos. A adopo desta tecnologia confronta-se porm com grandes dificuldades que resultam da ausncia de standards, da resistncia dos mdicos e dos elevados custos de implementao e de manuteno. Esta resistncia dos profissionais de sade a utilizarem os RMEs parece resultar dos elevados custos associados ao software e s redes e ainda a uma clara diminuio da produtividade, que alguns mdicos estimam em menos 10 a 20% . Novas solues so portanto necessrias. Os programas residentes na internet web based software e a computao em nuvem, podem ser a soluo para estas dificuldades. Acresce tambm que todas as propostas existentes no mercado no se adaptam ao mtodo clnico (caso a caso) que se aproxima mais da chamada produo por projectos. Uma proposta inovadora da Corrida Consulting incorporar os conhecimentos e as ferramentas da gesto de projectos na gesto dos casos clnicos. Com o Health Grouping, EEIG a Corrida Consulting procura reunir parceiros interessados em desenvolver uma plataforma para a sade que integre: a) RME b) Computao em nuvem c) Gesto de Projectos As empresas a integrar esta EEIG podero candidatar-se a fundos europeus, para I & D nesta rea, promover standards e candidatar-se a concursos a realizar dentro e fora da UE, optimizando recursos e knowhow. Os desafios so grandes e o esforo de todos bem necessrio. Joaquim S Couto, MD, MBA CEO Corrida Consulting, Ltd

HEALTH GROUPING, EEIG

Carta de apresentao 1. Infraestrutura de Cuidados de Sade ICS 2. Health Care Framework HCF 3. Medicina Orientada por Projectos POME 4. Agrupamento Europeu de Interesse Econmico 5. European Economic Interest Grouping 6. Anexos: a. Overview of International EMR/EHR Markets Accenture (public domain document) b. Project management can help to reduce costs and improve quality in health care services Artigo publicado no JECP

Infraestrutura de Cuidados de Sade Health Care FrameworkMelhor sade para todos Better healthcare for allA ICS uma ideia inovadora. O seu objecto o desenvolvimento de uma Infraestrutura digital para os sistemas de sade, baseada nos princpios da Gesto de Projetos. Consiste numa plataforma de software, residente na internet (computao em nuvem ou cloud computing), desenvolvida para armazenar e processar registos de sade electrnicos (RSE), atravs das ferramentas da Gesto de Projetos (GP). Este conceito associa, pela primeira vez, RSEs, a computao em nuvem e a Gesto de Projetos, para criar uma infraestrutura destinada a gerir a prestao de servios de sade de acordo com o princpio de que cada caso clnico um projecto e deve ser gerido como tal (1), para garantir a mxima eficcia e qualidade. Os RSEs tm um enorme potencial para melhorar a qualidade dos servios de sade (2,4), mas os benefcios tm sido limitados pelos custos de administrar grandes redes computacionais e pela dificuldade de integrar os dados disponveis. A computao em nuvem pode diminuir os custos do armazenamento das grandes quantidades de informao gerada pelos RSEs e pode disponibilizar estes dados, de forma instantnea, a uma escala global e de modo seguro. A computao em nuvem tambm minimiza os custos do software proprietrio para as empresas que fornecem servios de sade. Os programas podem ser instalados na nuvem e operados atravs de thin clientes, web browsers, tablets e outros dispositivos mveis, sem necessitar de software local. Esta soluo pode ser utilizada por grandes organizaes assim como por consultrios, sem os custos punitivos de uma pequena operao. Uma sondagem efectuada pela Comisso Europeia (3), em 2007, demonstrou que 87% dos mdicos europeus usam regularmente computadores e que 48% destes tm ligaes de banda larga internet facilitando o desenvolvimento e a implementao da ICS.

Finalmente, o conhecimento e as ferramentas da Gesto de Projetos podem ser utilizados para integrar toda a informao disponvel para fornecer resultados de excelncia aos doentes, atempadamente, com controlo de custos e com a mxima qualidade. A Gesto de Projetos uma componente essencial deste conceito ICS. Uma vez que os resultados procurados por cada doente so nicos (tal como num projecto), a adopo de uma produo por projectos tem um enorme potencial para controlar os custos e, em simultneo, melhorar a qualidade. Os mdicos e os outros profissionais de sade podem utilizar o ICS para gerir todas as actividades e processos relacionados com os doentes, incluindo o planeamento, o agendamento, a monitorizao (ex: relatrios normalizados, notificaes, alertas, bases de dados centralizadas), o controle da qualidade (ex: planos de qualidade, satisfao dos utentes, feedback), critrios de sucesso (ex: resultados obtidos), tradeoffs entre o custo, o tempo e a qualidade, e o controle de custos. Modelos de PM (templates) podem fornecer guidelines aos clnicos. Ao mesmo tempo, a Gesto de Projetos tambm pode fornecer as ferramentas para comparar diferentes prestadores de servios, um desafio que at agora, tem sido praticamente impossvel de atingir. Um estudo recente sobre as tecnologias de informao na sade, conduzido pelo Center Medicare Advocacy (4), enunciou os benefcios que se podem obter de um uso mais intensivo das ITs nesta rea, reconhecendo tambm os obstculos. Ns pensamos que a ICS pode alavancar os benefcios e reduzir os obstculos.

Benefcios:1. Diminuir o crescimento da despesa 2. Facilitar a coordenao de prestao de servios 3. Aumentar a segurana atravs da Gesto de Doenas 4. Reduzir a sobre utilizao dos exames complementares de diagnstico 5. Monitorizar e detectar epidemias O ICS pode reduzir os custos das ITs, em hardware, software e gesto de redes. Tambm, a adopo da produo por projecto na sade, juntamente com as correspondentes ferramentas de software, pode facilitar a coordenao da assistncia mdica, a gesto clnica e o controle de custos.

Dificuldades:1. 2. 3. 4. Financiar os custos iniciais Criar formatos normalizados para a partilha de informao Garantir a confidencialidade e a privacidade do sistema Partilhar o custo da implementao

Absorver os elevados custos iniciais, partilhar o custo da implementao e criar formatos estandardizados, est no centro da computao em nuvem. A ICS, ao adoptar a computao em nuvem, beneficiaria da experincia acumulada nesta rea. A confidencialidade e a privacidade podem ser melhor geridas centralmente, em vez de em pequenas redes. A ICS INFRAESTRUTURA DE CUIDADOS DE SADE pode representar um paradigma disruptivo para as indstrias da sade, abrindo caminho para uma concorrncia de soma positiva. A INFRAESTRUTURA DE CUIDADOS DE SADE tambm se enquadra na economia do conhecimento, focada no sector tercirio.

ANLISE SWOT:Foras

Melhoria da qualidade dos servios de sade com custos inferiores. Possvel apoio da UE para melhor integrao dos cuidados de sade na Europa.

O programa pode ser implementado em fases. Os diversos parceiros (Hospitais, Companhias de Seguros, etc.) podem ter os seus prprios workflows e layouts. Fraquezas

Pode suscitar preocupaes sobre a privacidade dos dados. Mtodos biomtricos para aceder aos registos de sade electrnicos podem ser usados para ultrapassar esta dificuldade. Oportunidades

A maior parte dos pases esto actualmente a considerar reformas dos sistemas de sade. Os registos digitais parecem ser a grande tendncia. A possvel integrao com pacotes de software comerciais, como por exemplo a Microsoft Project, pode representar grandes oportunidades de negcio. Ameaa

Arena muito competitiva. Necessrio promover parcerias entre empresas que se especializaram na gesto da sade, empresas de hardware, empresas de software e empresas de Gesto de Projetos.

Bibliografia:1. Couto, J.: Project management can help to reduce costs and improve quality in health care services. J Eval Clin Pract., Jan; 14 (1): 48-52, 2008

AbstractRationale, aims and objectives

Health care spending has increased steadily over the last 50 years, but there is a consensus that this trend cannot continue indefinitely. The ideal solution would bring about cost reductions coupled with improvements in quality, but this has remained an exclusive goal. In this article, a novel idea is proposed that consists of adopting a project type of production in health care, instead of the current mass production methods used in the modern health care factories.

MethodsThe author demonstrates that health care services in general and medical services in particular, fit the category of projects. This is accomplished through a comprehensive study of the mains features of projects and medical services and comparative analysis.

Results and ConclusionThe author infers that the productivity gains by Project management to so many other human endeavors can be brought to health care. Its also claimed that if project management were adopted in health care, then physicians would be the natural project managers because of their proficiency with casuistic method (one-off, non-repetitive production) and because of their experience in managing their patients cases that is indeed what doctors have been doing for as long as their profession exists.

STUDY CONFIRMS PAPERLESS HOSPITALS ARE BETTER FOR PATIENTS.2. STATEWIDE

Johns Hopkings Medicine.http://www.hopkingsmedicine.org/Press_releases/2009/01_26_09.htlm 3. What

Percentage of General Practitioners in Europe Use Computers?Health Beat.http://www.ihealthbeat.org/data-points/2008/what-percentage-ofgeneralpractitioners-in-europe-use-computers.aspx 4. HEALTH

INFORMATION TECHNOLOGY AS A HEALTH CARE REFORM TOOL.Center for Medicare Advocacyhttp://www.medicareadvocacy.org/Print/2009/Reform_09_06.04.HIT.htm 5. Christensen,

C.M.: The Innovators Prescription: A Disruptive Solution

for Health Care. MCGraw Hill, 20046. Porter,

M., Teisberg, E.: Redefining Health Care: Creating Value-Based Competition Results. Harvard Business Press, 2006

HEALTH CARE FRAMEWORK Project-based Health care FrameworkBy Joaquim Couto, MD, MBA * Better health care for all

The Health Care Framework (HCF) is a novel idea. Its an object the development of a new digital framework for health care, based on the principles of Project Management. It would consist of a software platform (based on cloud computing) designed to store and process health care information, together with the management tools of Project Management. This idea would bring together, for the first time, paperless medical records, cloud computing and project management, to build an innovative framework to manage the delivery of health care services according to the principle that each patients cases a project and should be managed as such (1), in order to obtain cost-efficiency gains and ensure the quality of the results delivered. Digital medical records have a huge potential to improve the quality of health care services (2, 4), but its benefits have been hindered by the high costs of running large computer networks and by the difficulties of integrating the available data. Cloud computing can minimize the costs of storing the large amounts of data generated by medical records and it can make this data available, instantly, on a global scale, in a secure fashion. Cloud computing can also minimize the costs of proprietary software for health care providers. Programs can be installed in the cloud and operated through thin clients, web browsers, and mobile devices without requiring software installations. A solution can be used by large organizations as well as by individual practitioners, without the punitive costs of a smallscale operation. A survey conducted by the European Commission (3), in 2007, demonstrated that 87% of the European physicians already use

computers regularly and that 48% have broad band connections, there by facilitating the development and implementation of the HCF. Finally, the knowledge and tools of project management (PM) can be used to integrate all available information, in order to deliver excellent results to patients, on time, on budget, and with the highest quality. Project management (1) is an essential and innovative part of this program (idea).Since the results demanded by each patient are unique (just like in a project), the adoption of a project type of production has an enormous potential to control costs and, at the same time, improve quality. Doctors and other health care professionals can use the HCF to manage all patient related activities and processes, including planning, scheduling, monitoring (ex: standardized reporting methods, notifications, centralized information bases), qualitycontrol (ex: means-ends, quality plans, satisfaction, feedback), success criteria (ex: target achieved, cost-time-quality tradeoffs) and cost control. PM templates can provide useful guidelines to practitioners. Simultaneously, PM can also provide the tools to compare the results obtained by different providers, a challenge that, so far, has been almost impossible to achieve. A recent study about health information technologies, conducted by the Center for Medicare Advocacy (4), listed the benefits that can be accrued by a more intensive use of its in healthcare, as well as recognizable obstacles. We find that HCF can leverage the benefits and greatly minimize the obstacles.

Benefits:1. Slowing Growth in Health Care Expenditures 2. Facilitating Care Coordination 3. Increasing Patient Safety Managing Chronic Conditions 4. Reducing the Over utilization of Laboratory Testing and Imaging Services 5. Monitoring and Detecting Disease Outbreaks The HCF can reduce it costs, with hardware, software and management of the infrastructure. Also, the adoption of a project production in healthcare, together with the necessary software tools can facilitate care coordination, disease management and cost control.

Obstacles:1. 2. 3. 4. Absorbing High Start-Up Costs Creating Standard Formats for Data Sharing Assuring Confidentiality and Privacy of HIT Systems Sharing the Cost of Implementation

Absorbing high start-up costs, sharing the cost of implementation and creating standard formats, is at the very core of cloud computing. Therefore HCF would definitely minimize these obstacles. Confidentiality and privacy can be managed more professionally in a centralized manner than in multiple small networks. The HCF or HEALTH CARE FRAMEWORK can offer a new paradigm for the Health Care Industries, disrupting the status quo (5) and paving the way for a positive sum competition (6). The HEALTH FRAMEWORK is also an idea that fits the profile of the knowledge economy, focused on the tertiary sector. It can generate highly skilled jobs and create value through innovation.

SWOT Strengths Better quality health care with lower costs. Possible EU support for health care integration in the EU. Program can be implemented in phases.Different customers (hospitals, insurance, etc) can have their own work flows and layouts.

Weaknesses Need to be careful about privacy concerns. Biometric data could be used to access medical records and overcome this difficulty. Opportunities Most countries are currently reforming their health care systems. Paperless seems like the trend. Possible integration into software packages like Microsoft Project can be business opportunities. Threats Competitive field .Possible needs to bring together different companies that are specialized in health care management, hardware, software and Project Management.

References:1. Couto, J.: Project management can help to reduce costs and improve quality in health care services. J Eval Clin Pract., Jan; 14 (1): 48-52, 2008

AbstractRationale, aims and objectives

Health care spending has increased steadily over the last 50 years, but there is a consensus that this trend cannot continue indefinitely. The ideal solution would bring about cost reductions coupled with improvements in quality, but this has remained an illusive goal. In this article, a novel idea is proposed that consists of adopting a project type of production in health care, instead of the current mass production methods used in the modern health care factories.

MethodsThe author demonstrates that health care services in general and medical services in particular, fit the category of projects. This is accomplished through a comprehensive study of the main features of projects and medical services and a comparative analysis.

Results and ConclusionThe author infers that the productivity gains brought by project management to so many other human endeavors can be brought to health care. Its also claimed that if project management were adopted in health care, then physicians would be the natural project managers because of their proficiency with the casuistic method (one-off, non-repetitive production) and because of their experience in managing their patients cases that is indeed what doctors have been doing for as long as their profession exists.

2.STATEWIDE STUDY CONFIRMS PAPERLESS HOSPITALS ARE BETTER FOR PATIENTS.Johns Hopkins Medicine http://www.hopkinsmedicine.org/Press_releases/2009/01_26_0 9.html

3. What Percentage of General Practitioners in Europe Use Computers?Health beat. http://www.ihealthbeat.org/data-points/2008/whatpercentage-ofgeneral- practitioners-in-europe-usecomputers.aspx

4.HEALTH INFORMATION TECHNOLOGY AS A HEALTH CARE REFORM TOOL.Center for Medicare Advocacy. http://www.medicareadvocacy.org/Print/2009/Reform_09_06.0 4.HIT.htm 5. Christensen, C.M.: The Innovator's Prescription: A Disruptive Solution forHealth Care. McGraw Hill, 2004 6.Porter, M., Teisberg, E.: Redefining Health Care: Creating Value-BasedCompetition on Results.Harvard Business Press, 2006 *Author:Joaquim S Couto MD, MBA Av. da Boavista, N. 117 Sala 301 4050-115 Porto Portugal +351 962094454 jsacouto@gmail.com

Corridaconsulting

POMEProject Oriented Medicine

CORRIDA CONSULTING

Avenida da Boavista | 117 | 3 | sala301 | 4050-115 Porto |Portugal Telefones [+351] 226 005 446 / 447 | Fax [+351] 226 004 913 E-mail: jsacouto@gmail.com

POME Project Oriented MedicineA sade est em crise. Uma crise profunda e, at agora, sem fim vista, condicionada por factores de natureza poltica, econmica, social e tecnolgica. As populaes, nos pases ocidentais, tm expectativas de acesso universal e geral a cuidados de sade, gratuitos ou tendencialmente gratuitos na sua prestao. Ainda, exigem a eliminao das listas de espera e a garantia total da qualidade dos servios prestados. Os Governos tm procurado, at ao limite, satisfazer estas expectativas, mas o impacte econmico dos programas assistenciais pblicos acaba por se reflectir negativamente noutras reas de investimento, obrigando a escolhas politicamente complicadas e onerosas. Basta pensarmos que os custos com a sade j atingiram 10% a 15% do PIB, nos pases desenvolvidos, para compreendemos, de imediato, a situao. Fenmenos de natureza demogrfica e social afectam tambm este quadro. O envelhecimento das populaes sobrecarrega os sistemas de sade, porque os seniores necessitam de mais servios e at de servios mais dispendiosos. Por outro lado, a imigrao para a EU de milhes de indivduos, sem os quais a nossas economias estagnariam, colocam desafios adicionais que se traduzem em custos. A vertiginosa evoluo tecnolgica outra vertente que no podemos esquecer porque afecta o tempo de vida dos equipamentos e o seu perodo de amortizao, assim como obriga a despesas constantes de formao. Torna-se portanto prioritrio assegurar a eficcia de cada euro gasto na sade, de modo a obter o mximo de produtividade, com a melhor qualidade e ao mais baixo custo possvel. Esta perspectiva, sobre a qual no pode deixar de existir consenso, levou-nos a inquirir sobre a melhor forma de organizar a produo de servios de sade. A POME ou Project Oriented Medicine uma proposta de optimizao da produo de servios de sade atravs da

adopo dos conhecimentos e tcnicas do PM Project Management (Gesto de Projectos) pelas unidades de sade. A ideia original foi divulgada num artigo publicado no Journal Evaluation in Clinical Practice, da Blackwell, de 2006, da autoria Joaquim S Couto, com o ttulo Project management can help reduce costs and improve quality in health care services (Anexo Neste texto analisaremos o contedo desse artigo e abordaremos aspectos prticos na adopo do PM na sade. of de to I). os

A GESTO DE PROJECTOS PODE AJUDAR A REDUZIR CUSTOS E A MELHORAR A QUALIDADE DOS SERVIOS DE SADENeste artigo so analisados os diversos tipos de produo de bens e servios para se defender a tese de que s a produo por projectos se adequa bem sade. So definidos os conceitos bsicos, as competncias essenciais que devem ter os gestores de projectos e ainda so dados exemplos de como o PM se pode integrar na gesto mdica. O autor critica tambm as correntes que propem a massificao da produo dos servios de sade e afirma que embora os servios de sade de destinem a grandes massas, seria contraproducente tentar produzi-los em massa. A produo, a transformao de inputs em outputs, tem sido genericamente classificada em produo em massa, por lotes ou por projectos. A produo em massa, tipificada na produo do Ford Modelo T, caracterizada pela produo de grande nmero de itens idnticos. A produo por lotes ocorre quando a procura impe a modificao dos outputs a intervalos previsveis. Por exemplo, na produo de papel para paredes; a produo pra, os equipamentos so reconfigurados e a produo de novo retomada sem quebrasat prxima reconfigurao. A produo por projectos usada para itens individuais que s so produzidos uma vez. A organizao da Expo 98 ou de um aeroporto so exemplos grandiosos deste tipo de itens, mas os mesmos conceitos podem ser aplicados a quaisquer produtos nicos.

ProjectosO Project Management Institute (PMI), no Project Management Book of Knowledge (PMBOK 2004), define um projecto como uma tarefa temporria, efectuada para criar uma tarefa temporria, efectuada para criar um produto, servio ou resultado nico. Temporrio significa que cada projecto tem um princpio e um fim definidos. No se refere durao do projecto mas apenas afirma que um projecto no um esforo continuado, finito! Como, por exemplo, a construo de uma casa que tem de ser concluda entregue no prazo estipulado, no oramento estipulado e de acordo com as especificaes constantes no caderno de encargos. As equipas que se formam para

executar um projecto dissolvem-se quando o projecto termina e so afectadas a outras actividades ou projectos. nico, refere-se singularidade do projecto e no significa a ausncia de elementos repetitivos. Na construo de uma casa h muitos elementos repetitivos mas o projecto nico porque tem clientes diferentes, a localizao diferente, os fornecedores podem ser diferentes, etc. O desenvolvimento progressivo definido outra caracterstica dos projectos que resulta da sua natureza temporria e nica. Progressivo significa que se desenvolve por etapas e por incrementos sucessivos (PMBOK 2004). Por exemplo, numa casa o projecto pode iniciar-se apenas por uma localizao e medida que a equipa responsvel vai conhecendo melhor os objectivos do projecto e os requisitos essenciais. Neste sentido, estritamente tcnico, os servios de sade so projectos. Todos so temporrios porque tm um princpio e fim bem definidos, todos so nicos porque os doentes so uma singularidade e todos se desenvolvem progressivamente, medida que os tcnicos se vo inteirando do caso e delineando o espectro de resultados desejveis para a situao clnica em causa. Um programa um conjunto de projectos orientados para a obteno de certos objectivos comuns. No caso da sade, tratar um doente, por exemplo, com obesidade pode ser um projecto. Contudo, um programa para combater a obesidade numa determinada populao envolve, normalmente, um conjunto de projectos.

Gesto de ProjectosA gesto de projectos (PM) a aplicao de conhecimentos, competncias, ferramentas e tcnicas aos processos (actividades) do projecto com vista a assegurar os cumprimentos dos seus requisitos (PMBOK 2004). O gestor de projectos a pessoa responsvel por levar a bom termo o projecto. Segundo o PMBOK, gerir um projecto inclui: 1.Identificar os seus requisitos 2.Estabelecer objectivo claros e realistas

3.Balancear o espectro do projecto contra os requisitos de qualidade, tempo e custo 4.Adaptar as especificaes e planos s expectativas dos diferentes Stakeolders

Competncias especficasOs conhecimentos, mtodos, ferramentas e competncias do PM esto bem documentados e so do domnio pblico. Contudo os especialistas em PM sublinham que as equipas que gerem e executam projectos devem ter conhecimento que abranja: 1. 2. 3. 4. 5. O chamado Project Management Body of Knowledge Conhecimentos da rea especfica de aplicao do projecto Compreenso do contexto do projecto Conhecimentos e competncias genricos de gesto Competncias relativas ao relacionamento interpessoal

Entre as ferramentas e tcnicas especificas do PM (competncias especificas) til destacar brevemente algumas, como a chamada estrutura de decomposio do trabalho (WBS) ou Work Break Down Structure, o mtodo o caminho critico (CPA) ou Critical Path Analysis, para percebermos com se podero aplicar sade. O WBS uma decomposio hierrquica do trabalho a efectuar pela equipa de trabalho, orientada pelos respectivo requisitos, para atingir os objectivo do projecto. Simplificando, uma decomposio de todo o trabalho a efectuar em pequenos pacotes mais gerveis, isto , mais fceis de executar e controlar. Este procedimento permite que cada pacote do WBS seja oramento e sequenciado num diagrama que explicite possveis dependncias lgicas. O CPA um mtodo, desenvolvido pela DuPont, para analisar diagramas de execuo de projectos e calcular possveis datas precoces de incio e concluso de pacotes de actividades e possveis datas tardias de incio e concluso dos mesmos pacotes. Pacotes, ou actividades, sem tempo de sobra, isto , sem intervalo entre a data de incio precoce e a data tardia de concluso definem um caminho

crtico. Qualquer atraso na execuo de uma tarefa que se encontre no caminho crtico afecta o prazo e o oramento do projecto. A EVA um processo de monotorizao da execuo de projectos que determina desvios no prazo ou no oramento de um projecto. um mecanismo de controlo. Apesar de todos o projecto serem nicos, possvel recorrer a algoritmos e solues pr-formatadas de sucesso comprovado que correspondam s melhores prticas. Durante todo o ciclo da vida do projecto, as variveis interdependentes: tempo, custo e qualidade, tm de ser equilibradas e o melhor resultado possvel , por sim dizer, o ponto de equilbrio perfeito.

Aplicao sadeUma vez que os servios de sade so, tecnicamente, projectos legtimo inferir que possvel obter ganho de produtividade na sade pela adopo das tcnicas e ferramentas do PM . No artigo referido apresentado o exemplo de um doente com varizes primrias dos membros inferiores e o projecto do respectivo tratamento. definido o mbito do projecto, o WBS, a CPA e a EVA.O mbito do projecto discutido abertamente com o doente/cliente. Quais sos os objectivos a atingir e como ir ser avaliado a sucesso do projecto. Por desenvolvimento progressivo encontrada uma soluo para o caso especfico em anlise. A partir dessa soluo elaborada uma WBS, a CPA e estimado um prazo e um oramento. As ferramentas de controlo de execuo permitem alertar para possveis desvios e para as necessrias correces. No paradigma actual os tcnicos de sade preocupam-se apenas com a qualidade dos servios e, mais recentemente, com a produtividade dos departamentos funcionais em que operam. No sistema POME, so introduzidas e adicionadas as variveis tempo e custos de modo a conseguir a equilbrio ideal.

No paradigma actual um doente com varizes adicionado lista de espera e a performance da unidade funcional (Departamento de Cirurgia) avaliada pelo nmero de intervenes efectuadas, na unidade de tempo (ex.: Por ano). No sistema POME a soluo encontrada pode ser melhor adaptada a cada caso em anlise. Muitos doentes com varizes apenas pretendem conhecer os riscos que correm e, quando no correm riscos significativos, muitas vezes optam por no se submeter a qualquer tratamento. Outros necessitam de intervenes cirrgicas, mas sem urgncia e estas podem ser marcadas a longo prazo, com significativa poupana de recursos. Ainda, outros necessitam de intervenes urgentes e no devem ir para quaisquer listas de espera. No POME, a produtividade e o sucesso no so avaliados em funo do output funcional, mas sim em funo da concluso com sucesso do projecto. A avaliao da performance das unidades de sade pela produtividade funcionais agrava custos e compromete o sucesso dos projectos, em particular os prazos e a qualidade. Como Michael Porter afirma, no seu livro Redefining Health Care, em sade os resultados devem ser avaliados ao longo de todo o ciclo de tratamento e no por intervenes discretas.

Experincias pilotoA nica experincia conhecida, at data, de utilizao do PM em servio de sade, foi efectuada em Nova Iorque, por David Kaufman (Anexo II), para avaliar se estas tcnicas tm capacidade para auxiliar a garantir que os perodos de internamento no excedem os previstos nas tabelas de GDHs (Grupos de Diagnstico Homogneo). O mtodo de David Kaufman, designado Project Rounds, uma aplicao do PM, que privilegia a varivel tempo, como elemento de sucesso. O mtodo compreende: 1.Avaliao clnica 2.Planeamento 3.Agendamento 4.Monotorizao e controlo

Os resultados, embora preliminares, permitiram concluir que o PM pode contribuir para optimizar os cuidados de sade a doentes internados e, talvez mais importante, determinar que os tcnicos de sade, em particular os mdicos, se adaptam com facilidade aos novos mtodos de trabalho.

Evoluo na continuidadeO POME no obriga a rupturas, oferece, pelo contrrio uma nova perspectiva de anlise dos problemas de sade e o potencial de fazer mais e melhor com os mesmos ou at com menos recursos. O paradigma actual de prestao de cuidado de sade fixou-se na qualidade de servio prestados e na produtividade das unidades funcionais, menosprezando olimpicamente a variveis custo e tempo. O contributo do PM integrar, em equilbrio, a qualidade, os custos e o tempo, de modo a oferecer servios que correspondam e satisfaam a necessidades dos doentes/clientes. Esta nova viso permite novas estratgias para a rea de sade, tanto no sector pblico comono privado, e a implementao de medidas de gesto que eliminem conflitos, alinhem interesses e, em ltima anlise, vo ao encontro dos desafios que se colocam. As organizaes funcionais dos chamados hospitais-fbrica (R.Herzlinger) no do a resposta necessria, porque: 1.So pouco flexveis 2.Isolam a gesto dos profissionais 3.Isolam as diferentes unidades funcionais, entre si 4.Esto desadequadas a um fluxo de trabalho descontnuo e muito variado 5.As hierarquias tm tendncia a bloquear a realizao de projectos 6.Esto demasiado focadas sobre o output funcional 7.No permitem a formao de equipas transversais 8.Ignoram os custos e o tempo que leva cada projecto 9.Alimentam o chamado pensamento de grupo 10.No exploram a multidisciplinaridade

11.No tm uma cultura de risco 12.No conseguem nivelar a utilizao de recursos, precavendo-se para situaes de maior procura com excesso de capacidade, custa de downtime quando esta decresce. O PM supera estas dificuldades: 1.Designando claramente os responsveis pelo sucesso dos projectos 2.Atravs de matrizes de responsabilidade (TRM Task Responsability Matrix) 3.Com equipas multidisciplinares coesas 4.Definindo as actividades crticas para o sucesso do projecto 5.Eliminando as barreiras funcionais 6.Nivelando a utilizao de recursos 7.Partilhando a utilizao de equipamentos 8.Trabalhando com oramentos e analisando prospectivamente os custos 9.Analisando a relao tempo/custo 10.Focando no verdadeiro da qualidade 11.Alinhando o interesses do decisores com o interesse dos clientes 12.Apostando na formao contnua.

O PROJECT MANAGEMENT MATURITY MODEL (PMMM) A MUDANAA adopo do PM na sade constitui uma mudana estratgica que ter melhores possibilidades de sucesso se for planeada segundo os modelos comprovados. Atendendo a que a gesto de sade tem pouca experincia com a gesto de projecto, sugerimos que a mudana para o POME siga um modelo faseado, como o PMMM Project Management Maturity Model de HarolKerzner, do International Institute for Learning, Inc. Neste modelo, a excelncia em PM atinge-se em cinco fases: 1. 2. 3. 4. 5. Linguagem comum Processos comuns Metodologia singular Benchmarking Melhoria contnua

Linguagem comum (Durao de meses at 1 a 2 anos) a fase em que a organizao acorda para o PM! O principal objectivo desta fase a formao. A formao deve incluir todos os funcionrios da empresa e inicia-se com a gesto. Os executivos podem necessitar de cursos mais aprofundados, que em regra envolvem uma semana de formao contnua. Nesta fase, em que se desenvolve uma linguagem tcnica comum, quando surge, a maior parte das vezes, a maior resistncia mudana.

Processos comuns (Fase que se sobrepe e contnua a fase 1)Reconhece-se a utilidade do PM, a todos os nveis da organizao, e a necessidade de sistematizar processos, controlar custos e equilibrar a qualidade com o tempo e os custos. Segundo H.Kerzner esta fase tem um ciclo de vida que passa pelas fases: a) embrionria, b)aceitao pelo executivo, c)maturidade, d)crescimentoe e)aceitao pelos operacionais.

A principal resistncia encontrada nesta fase que a metodologia do PM pode ser percebida como perda de flexibilidade e capacidade de adaptao. Outra resistncia significativa aparece quando se procura introduzir um processo de contabilidade horizontal.

Metodologia singular (Durao varivel, atingindo vrios anos) a fase em que os interesses do todo so aceites e reconhecidos como tendo prioridade sobre os interesses funcionais. Tanto quanto possvel devem ser adoptados os mesmos mtodos em todas as actividades da organizao de modo a criar sinergias e uma cultura de cooperao, com forte apoio da administrao. Adopta-se o chamado PM informal, baseado em directivas gerais, em vez de procedimentos rgidos. Continua a formao e treino em PM e exalta-se a excelncia comportamental, reconhecendo as diferenas entre os comportamentos que se adaptam linha de montagem e os que se adaptam ao PM (sic) .

Benchmarking processo de comparar continuadamente as prticas da organizao com a melhores prticas globais na mesma ou noutras indstrias (sic).O objectivo procurar uma melhoria contnua. Passa por estabelecer um centro de excelncia em PM ou um PM Office e focar sobre o benchmarking quantitativo (processos e metodologias) e qualitativo (cultura).

Melhoria continuaNesta fase incorporam-se os resultados do benchmarking no planeamento e implementao de melhorias, para assegurar a excelncia da organizao e as vantagens competitivas resultantes dessas excelncias.

OCEANO AZULA adopo da POME constitui uma mudana significativa para as organizaes e um impacto enorme nas respectivas culturas. As dificuldades e os problemas no devem contudo ofuscar as oportunidades que se abrem, em territrios pouco navegados e sem competio. O que Chan Kim e Rene Mauborgne chamam oceanos azuis.

CONCLUSOH uma crise na sade, que se manifesta em todos os pases ocidentais. Trata-se de uma crise com mltiplas origens e que obviamente no se vai desvanecer com nenhuma soluo milagrosa. Esta crise obriga, porm, a examinar o modo como os cuidados de sade so produzido e a introduzir, sempre que possvel as melhorias necessrias, para conseguir melhor eficcia. Neste texto introduzido um conceito novo, a POME, como proposta para melhorar a produo dos servios de sade. uma proposta inovadora que parte de uma reflexo sobre a natureza dos servio de sade, enquanto objectos de produo e estabelece o seu enquadramento adequado numa produo por projectos e no, como tem vindo a ser tentado no ltimos anos, numa produo em massa, em organizaes compartimentadas segundo funes. ainda sugerido um meio para adoptar a metodologias do PM na sade. O PMMM. Em ltima instncia as solues a adoptar dependero de cada organizao, das suas vises, objectivos e estratgias. A finalidade deste texto dar continuidade ao artigo original da autoria de Joaquim S Couto e abrir as portas da POME a todos os que se interessam por estes assuntos.

Leituras sugeridas:Anexo I Couto, JS: Project management can help to reduce costs and improve quality in healthcare services. Accepted for publication in 2006, JECP Anexo II Kaufman, D: Using project management methodology to plan and track inpatient care. http://www.jcrinc.com /11375/ Sites: PMI http://www.pmi.org APOGEP Associao Portuguesa de Gesto http://www.apogep.pt/ Livros Porter, M. e Teisberg, E.: Redefining Health Care, Harvard Press 2005 Herzlinger, R. Et al: Consumer Driven Health Care, Harvard Press 2004 Kerzner, H.: Using the Project Management Maturity Model, Wiley 2005 PMBOK 2004: PMI

PROJECT MANAGEMENT CAN HELP TO REDUCE COSTS AND IMPROVE QUALITY IN HALTH CARE SERVICESBy Joaquim Couto, MD, MBA Management is the art of getting things done through people-Mary Parker Follet

AbstractHealth care spending has increased steadily over the last fifty years but there is a consensus that this trend cannot continue indefinitely. The ideal solution would bring about cost reductions coupled with improvements in quality, but this has remained an illusive goal. In this article a novel idea is proposed that consists of adopting a project type of production in health care, instead of the current a project type of production in health care, instead of the current mass production methods used in the modern health care factories. The author demonstrates that health care, instead of the current mass production methods used in the modern health care factories. The author demonstrates that health care services in general, and medical services in particular, fit the category of projects and, therefore, infers that the productivity gains brought by project management to so many other human endeavors can be brought to health care. The author also claims that if project management is adopted in health care, then physicians would be the natural project managers because of their proficiency with the casuistic method (one-off, non-repetitive production) and because of their experience in managing their patient s cases that is indeed what physicians have been doing for as long as their profession exists.

IntroductionPhysicians are true managers. They are managers not only because they master the art of getting things done thought people, to use to beautiful words of Mary Parker Follet (Follet 1982), but also because, physicians devote most of their practice to setting goals and allocating resources, to achieve them, in the most efficient and judicious possible. Physicians have managed their patients (clients) cases for centuries with great success. Over the last fifty years, however, a revolution occurred in health care. Medical specialization drove physicians away from their management responsibilities and attracted them to more operational duties. At the same time, professional managers, highly concerned with the bottom line, made their appearance in the health care scene because of the huge capital investments necessary for health care facilities to continue offering the latest medical technology. The result was the emergence of the modern health-care factory, a highly bureaucratic facility with a functional structure run by command and control, more focused on productivity ratio than on customer satisfaction. With our modern and sophisticated health-care factories, are we better off today? Life expectancy has never been so high, but there is disillusionment amongst health care workers and, most alarmingly, governments and think tanks consider that the current health care provision system are unsustainable, and agree that changes are necessary. Sending in health care, which varies between 8 and 14% of GDP in most western countries, cannot continue to grow indefinitely (Herzlinger 2004).Costs have to be slashed, but managers bleakly wonder why? Rationing health care? Compromising quality? The ideal solution would reduce costs whilst improving quality, but this has remained as illusive goal. Regina E. Herzlinger (Herzlinger 2004), of Harvards Business School Health Care Initiative, thinks that the solution to this conundrum will only emerge with the implementation of consumer driven health care systems. She reminds those in doubt that most experts also scoffed at Henry Fords promise to improve both costs and quality in

automobiles, and id it! How? Though mass production - Focusing on production, with an early stage focused factory and an integrated system. In her vision, focused health-care factories, like the Shouldice clinic, in Canada, can do the trick and help improve both costs and quality in health care. Clearly, this sounds like a passionate defense of more mass production in health care. Unfortunately, I fear that dead white men like Mr. Taylor or Mr. Ford will not be able to help us, because their time and motion studies or the assembly line have a rather limited use in medicine. The casuistic approach used by physicians does not permit the standardization of processes necessary for mass production (Tonelli 2006, Miles et al 2006). Production, the transformation of inputs into outputs, has been generically classified into three categories mass production, batch production and project production. Mass production, typified in the production of Ford Model T, is characterized by the production of a large number of identical items. Batch production is used when outputs are required to be modified at specific intervals to accommodate particular market demands, like the color and texture of wallpaper. When changes become necessary the production system is shut down, retooled and reconfigured, and the process started up again to produce the next batch. Project production is used for one-off, individual items. As a result of this singularity, there is no previous learning curve on which to rely and high levels of complex management planning and control may be required (Roberts et al 2004).Building a house, for instance, falls within this latest category because of the uniqueness of the problems that are likely to be encountered in each project. Organizing a social event, or, on a grander scale, the construction of the Channel Tunnel are also projects. Health care delivery, in this classification would obviously fit in the project production category, because each patient s case presents unique problems that require tailored solutions and, therefore, are one-off, non-repetitive items. Physicians managing patients cases would be considered project managers, from a production perspective.

In this paper I assert that medical care fit perfectly in the general scope of project management. Physicians can therefore, utilize the knowledge, techniques and tools of the project management to optimize health care delivery, with greater benefits or patients and society at large. The simultaneous control of costs and quality that project management has delivered to so many human endeavors can and should be adopted in health care.

ProjectsA project is defined in the Project Management Book of Knowledge (PMBOK 2004) o the Project Management Institute (PMI) as a temporary endeavor undertaken to create a unique product, service, or result. Temporary means that very project has definite beginning and a definite end. It does not say anything about the duration of the project itself but only that a project is not an ongoing effort, it is finite. The construction of a building it is the most obvious example, with a clear life cycle from inception to conclusion. The client wants the building concluded and delivered on time, on budget and according to the specifications put forward in the statements of works (SOW).The teams that are assembled to carry out specific projects are disbanded when each work is concluded and are reassigned to others tasks, precisely because of the temporary nature of projects. The uniqueness of project deliverables is another essential characteristic of the projects. Uniqueness describes only the projects singularity and does not imply the absence of repetitive elements. In the construction of a building there are many repetitive elements but each building is unique because of different ownership, location, contractors and so on. Progressive elaboration is another characteristic of project that is closely related to their temporary and unique nature. Progressive means developing in steps, and by continuing increments. For example, the projects scope will be broadly described early in the project and made more explicit and detailed as the projected team develops a better and more complete understanding of the objectives and deliverables (PMBOK 2004). The project of a building can start only with a purpose and location and be developed in steps and by continuing increments. Do medical services qualify to be considered projects? Certainly! All medical services that I can think of are temporary, unique and developed in steps. They are temporary because they have a definite beginning and a definite end, they are unique each patient is a

singularity and they develop in steps, as the physician develops a more complete understanding of the scope of the services or results that are to be delivered. In this text I shall use the example of a patient with varicose veins to demonstrate my contention that medical services fit the general category of projects, because of the enormous prevalence of this problem in the population, the familiarity that physicians have with venous disorders and also because it is one of pathologies that I treat most frequently. The project starts when the patient with varicose vein first seeks medical assistance for her problem. The scope of the medical service to be delivered (the project) is assessed in the first office visit. What is the service to be or result that the patient (the client) seeks? Most of my patients want to be relieved of their symptoms and want to improve their looks .After an initial evaluation, I usually order a Doppler exam and, if I suspect that surgerysgoing to be necessary , blood tests and ECG. When the results of these exams are available, I discuss with the patient the possible options for her treatment.The scope of the services awaiting delivery then become clearer and usually a specific course of action is chosen. When surgery is considered to be necessary further arrangements need to be made. I have to book the case in a local hospital, a team has to be assembled for the surgery and a timetable has to be drawn. Adjustments are usually necessary as the case progresses, either at the patients request or due to do the availability of the resources. Eventually the patient is discharged, once the agreed services or results are delivered. This scenario, a familiar one to any health care professional, illustrates the temporary, unique and progressive nature that characterizes medical services and qualifies them as project. The physician should be regarded as a project manager working for a client whose the patient. Sometimes patients with varicose veins just seek advice, a prescription for a pair of elastic stockings or a medical report to take to their family physician. Does that service qualify as a project? Yes! It is a one-off, non-repetitive activity that cannot be standardized. My

recommendations vary according to a multitude of factors, like the patients age, gender, profession, place of residence and so on. It is a service that does not take the time and planning necessary to carry out a surgical procedure, however the duration or the difficulty are not the criteria by which a service qualifies as a project , it is so because it is finite and unique. At this point it is useful to distinguish between a project and a program. A program is defined as a set of identifiable projects aimed at achieving some goal or objective (Roberts t al 2004). Programs do not have end dates and will run until a decision I taken to stop them. The classical textbook example of a program would be a governments program to reduce pollution. In the health status of the populations and these programs are usually composed of specific and identifiable projects. A program to fight avian flu can include projects to develop a new vaccine and at the same time projects to divulge information and increased general awareness in the public about the problems posed by the avian flu virus. Projects can be added or removed from a program according to its general goals and objectives. The effort to provide lifelong health care assistance to any individual in a given population can be regarded and managed as a program and particular services that are necessary during the life of that individual can be regarded as project.

Project ManagementProject management is the discipline that deals with the management of the projects, forgive the tautology. In the PMBOK PM is defined as the application of knowledge, skills, tools and techniques to project activities to meet project requirements. Project management is accomplished through the application and integration of the project management processes of initiating, planning, executing, monitoring and controlling and closing.The project manager is the person responsible for accomplishing the project objectives. The PMBOK goes on to specify that managing project includes: 1. Identifying requirements. 2. Establishing clear and achievable objectives. 3. Balancing the competing demands for quality, scope, time and cost. 4. Adapting the specifications, plans, and approach to the different concerns and expectations of the various stakeholders. Project management point out element of project management first came to light in the great construction works of history, like the Pyramids, the Great Wall of China, or the Roman roads and aqueducts. Now, this cant be entirely true because it would make project management the second oldestprofession in the world and, physicians, we know that lightly unlikely. The history of PM can be traced back to the second half of the twentieth century. It started with the arm race and the need for the US defense industries to control the large overruns, in time and cost, of their projects. Crucial landmarks were the development of the Program Evaluation and Review Technique or PERT (developed in 1958 for the Polaris missile submarine program) and, almost at the same time, the development of the Critical Path Method or CPM, by DuPont Corporation. Professional bodies emerge in the late 60s. In the USA is the PMI Project Management Institute and in the UK the APM Association of the Project Management. The APM produced its Body of Knowledge in 1988 and collaborated in the preparation of the British Standard BS6079 (1996) as well as in the European Standard ISO100006 (1997). These documents helped to frame PM as a profession. The international body that coordinates PM globally is the International Project Management Association (IPMA).

Core CompetenciesThe knowledge, methods, tools and skills use in PM are well documented and in the public domain. However, as experts in the field point out effective project management requires that the project management team understands and use knowledge and skill from at least five areas of expertise. 1. The Project Management Body of Knowledge. 2. Application area knowledge, standards and regulations 3. Understanding the project environment. 4. General management knowledge and skill. 5. Interpersonal skills. Amongst the tools and the Techniques that are unique to PM (core competences), it is useful to describe very briefly a few, such as the work breakdown structure (WSB), critical path analysis (EVA), to demonstrate their potential impact in the delivery of medical services. Once defined a projects scope that is the work that needs to be accomplished to deliver a product, service, or result with the specified features and functions the project manager is responsible for breaking down the work to be done into smaller, more manageable pieces of work. The WBS can be defined as a deliverable-orientated hierarchical decomposition of the work to be executed by the project team, to accomplish the projects objective (PMBOK 2004). This procedure allows that each piece of work, or activity, can then be budgeted and sequenced in a diagram, or schedule network that set logical dependencies amongst the different activities that need to be performed. The CPM is a method developed by the DuPont Corporation (Nokes et al 2003) to analyze schedule networks and provide information about early start an finishing dates, for all scheduled activities. Activities with no spare time, that is with a zero difference between their early starting dates and late finishing dates are considered critical and define a Critical Path. Any delays in the activities in the critical pat influence the schedule and the budget of the project. EVA is a type of milestone monitoring applied specifically to determine cost and schedule variance for components sections of a project (PMBOK 2004).Cost variance provide information about the difference between the budgeted cost of the work performed and the actual cost and is a fundamental tool of cost control.

Although, by definition, each project is unique, project managers can use templates from previous projects to draw their WBS, and therefore resort to models and solutions that proved successful in the past. Throughout the lifecycle of a project, I see the project manager as a juggler, simultaneously juggling three interdependent variables that are time, cost and quality. The ultimate performance depends on the perfect equilibrium of these variables.

Medical practiceSince medical services fall within the category of projects it is perfectly legitimate to infer that physicians can obtain productivity gains by learning PM and adopting its techniques and tools. In the example that I provide, of the patient with varicose veins, it is obvious that the project to be delivered by me, the scope of which is eliminate the patients varicose veins and therefore most of its symptoms, can be decomposed into several smaller pieces of work that can be scheduled and budgeted separately. A schedule network, of these different items, can be drawn, a critical path determined and budget estimate calculated. The Project Logical Evaluation (PLE) is the process of taking the WB packages and determining the sequence in which is they are to be carried out (Nokes et al 2003).In my example, the blood tests, ECG and Doppler exampackage have to be completed before the surgical procedure itself, but their relative sequence is flexible. The final cost and the quality of my project depends on the cost and quality of each package and the way they are assembled. Using PM, we can procure the package suppliers that offer item with the best price/quality relationship and bring down costs at the same time that quality is safeguarded or upgraded. The WBS templates are tools that be extremely useful to physicians that adopt PM. Although each project is unique, a WSB from a previous project can be used as a template for a new project, since some project will resemble another prior project to some extent (PMBOK 2004). Therefore a practicing physician can use the experience drawn from previous cases and apply it to current ones, benefiting from the experience and knowledge of his/her colleagues. Evidenced-base medicine proponents have always pointed out that clinical practice is frequently erratic because its not necessarily based on the best evidence available but on content expertise and clinical experience (Sackett, 1996).WSB templates can integrate pathophysiological principals and the best epidemiological evidence available, a well a clinical expertise, experience and value to provide solution that are uniform, yet flexible enough, to satisfy the unique demands of each patient.

Information technologies (IT) are crucial n PM. Although there are no clear cut rules, it is generally believed that it is fundamental to manage large projects or a large number of small projects simultaneously. From my readings and experience, I identified a rule of thumb that I call the 12/12 rule. It is beneficial, or even indispensable, when the project manager handles more than 12 cases simultaneously and each case is composed of 12, or more, identifiable pieces of work .In a retrospective analysis of my own practice I realized that I was handling simultaneously an average of approximately 60 cases and that each case involved, on average, 12 to 18 pieces of work. We can therefore extrapolate that using PM to deliver medical services and result is going to require the support of specialized software platforms. The time that we were managing out patients cases with a pad, a pen and the space between our ears is probably over!

DiscussionProject management has been extensively used in the health care industries. It has been used, for example, in the construction of new health care facilities, to implement it projects or by pharmaceutical industries to develop new drugs. The PMI recognized this when it created a Special Interest Group (SIG) for health care: It is our belief there is a need for a healthcare SIG to serve the needs of the PMI membership that work in healthcare. Specifically, health plans, health care providers, clearinghouses, business partners, or consulting firms. Subsets of this population include those who implement projects specific to information technology, regulatory, obligations, business process re-engineering, etc. The Health Care Industry is changing like never before and I beginning to recognize the need for project managers (PMI 2006). The novelty, in this paper, is to propose that PM can and should be used to deliver medical services and results. This concept as far as I can tell, from searching the medical literature, in English, and web sites dedicate to PM, is entirely new and was never theorized or discussed in the specialized literature. I started by demonstrating that the delivery of medical services fits the general category of projects, as defined in the PMBOK, of the PMI. This is an epistemological premise that appears undisputable. Secondly, I affirmed that, since the delivery of medical service is a project, in the PM sense, there are gains to be obtained by adopting PM techniques. Health care productivity can be increased, costs can be slashed and quality can improve. This, I realize, is something that will have to be demonstrated empirically, but it is more than simple wishful thinking. It is a legitimate conclusion of the first premise since PM has delivered those results to all other industries that use it. It can, therefore, be inferred that PM will accrue the same benefits to health care. Fortunately, this is an empirically falsifiable conclusion. The examples provided are too basic to support the second conclusion and are included only to demonstrate that the problems analyzed correspond to real and practical situation that physicians deal with on a daily basis.Situations that can benefit from better planning, team work and improved communication between all involved in health care.

In the introduction to this paper, I tried to put in context some of the problems that affect the management and delivery of health care services. In my point of view, part of those problems result from the erroneous categorization of health care services as mass products and accordingly the attempt to mass produces them in health care factories. The strategies implement at a functional level, in these factories, constantly collide with the flexibility required for project production, originating difficulties that waste energies and resources. The end result is an impossibility to curb costs while maintaining or improving quality, an illusive goal that has become a sort of Holy Grail for health care managers. The focused health care factories, that Regina E. Herzlinger(Herzlinger 2004) regards as a means to achieve the goal, correspond, only, to one of those rare instances where mass production can be used. The Shouldice Clinic that Herlinger sees as an example to follow, only treats hernias and developed an assembly line to treat them. It is a solution that cannot be generalized. If there is a Holy Grail, if it is possible to bring down costs while improving quality, Im convinced it is only going to happen thought a counter revolution in health care that puts the physicians back at the helm of the entire management of their patients cases, like true projects managers.

ConclusionThe production method for delivering health care services in general or medical services in particular, is analyzed in this article. Its proposed, and demonstrated, that medical services before belong to the general category of projects and, therefore, productivity gains can be achieved in health care if an adequate method of production is employed. It is also stated that if project management is used to deliver health care services, physicians are the natural project managers.

Acknowledgements I was studying project management for my MBA when I received an email from Prof. Andrew Miles to comment (Couto 2006) on an article, by M. R. Tonelli, proposing a casuistic approach to integrate evidence intro clinical practice (Tonelli 2006). The idea to use project management to deliver medical services was inspired by reading Tonelli`s articles because the casuistic approach that is proposed results from the some singularity that is present in projects. I would like to acknowledge also the contribution of my daughter Sarah Couto with suggestions and editing of this text.

BibliographyAPM - Association of Project Management. http://www.apm.co.uk Couto J.(2006) Can we forget how to treat patients? Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches.Journal of Evaluation in Clinical Practice12, 248-256. Follet M.P (1982) Dynamic Administration - The Collected papers of Mary Parker Foller. Hippocrene Books, New York, USA. Herzlinger R.E.(2004) Consumer driven Health Care Implications for Providers,payers and Policy-makers. Jossey Bass Wiley. San Francisco, CA, USA. IPMA - International Project Management Association.http://www.ipma.ch

Miles A., polychronis A., Grey J.(2006) The evidence based health care debate 2006. Where are we now? Journalof Evaluation in Clinical Practice12, 239 -247.Nokes S., Greenwood A.(2003) The Definitive Guide to Project Management. PrenticeHall, Edinburgh, UK. PMBOK (2004) A Guide to the Project Management Book of Knowledge. Project Management Institute, USA PMI Project Management Institute.Http://www.pmi.org Roberts A., Wallace W.(2004) Project Management. Edinburgh Business School Course, Heriot-Watt University, Edinburgh. Sackett D., Rosenberg W., Gray J., Haynes R., Richardson W. (1996) Evidence Based Medicine: What it is and What it isn`t. British Medical Journal 312, 71- 72 Shouldice Hernia Center.http://www.shouldice.com

Tonelli M.R (2006) Integrating evidence intro clinical practice: an alternative to evidence- based approaches. Journal of Evaluation in clinical Practice12, 248-256. * Joaquim Couto, MD, MBA Av. da Boavista, 117 Sala 301 4050-115 Porto Portugal http://www.joaquimcouto.com jsacouto@gmail.com

Using Project Management Methodology to Plan and Track Inpatient Care Article-at-a-Glance BackgroundEffective care of each patient throughout a hospital admission involves executing a specific set of tasks to produce a favorable outcome within an appropriate time frame. The ProjectRoundsTM methodology, which can be implemented using widely available software, incorporates the principles of project management in planning and control hospital inpatient care. It consists of four stages-clinical assessment, planning, scheduling, and tracking.

Overview of ProjectRounds and ExampleAs an example, a 68-year-old-man is admitted with pneumonia. In clinical assessment, the admitting physician uses an assessment tool that prompts her to list all patient`s clinical issues, define the conditions that need to be met to discharge the patient, highlight special problems, and list any consultations, diagnostic test, and procedure that are planned. In planning, the work breakdown structure-a tabulation of all the tasks in the project (the admission) is created. In scheduling, a project schedule is generated, and in tracking, the clinical team evaluates and monitors the project`s course. During interdisciplinary clinical rounds, the progress of the patient`s hospital care can be tracked and quantified by employing the percent complete method. Tracking can be used as a dashboard, providing a concise summary of the care that needs to be and has been rendered to the patient.

Summary and Next StepsApplying the tenets of project management can optimize the process of providing health care to hospital inpatients. Each hospital admission is work that we do only one time, that is, it is a project. Although admissions for the same, or similar, diagnoses may involve the performance of similar or somewhat standardized tasks, each patient presents with a unique set of demographic, socioeconomic, medical, and other issues. Hence, effective care of each patient throughout a hospital admission involves executing a specific set of tasks to produce a favorable

outcome within an appropriate time frame. As pointed out by Juran, a project is a problem schedule for solution .1)The paradigm shift reflected in defining inpatient care throughout the hospital admission as a project rather than as a component of ongoing hospital operations is mandatory to achieving high-quality outcomes. Moreover, by shifting hospital care into the project environment, the body of knowledge that constitutes project management can be brought to bear on the key issue facing clinicians and administrators involved in hospital care-how to balance cost, quality, and time (length of stay[LOS])considerations. Given the LOS consideration created by the diagnosis-related group (DRG)-based prospective payment system, and in recognition of the prevalence of medical errors, 2) there is an acute need to develop and implement a formalized yet flexible methodology that allows clinicians to deliver care that maximizes patient safety in a fiscally and temporally efficient manner. This article describes the Project Rounds, methodology, which incorporates the principals of project management in the planning and control of hospital inpatient care.

Overview of ProjectRounds and ExampleAn overview of ProjectRounds is depicted in Figure 1. An example is provided to illustrate the details of ProjectRounds: A 68 year-old-man, A.B., with a history of Type 2 diabetes mellitus, chronic renal failure, coronary artery disease, and hypertension , is admitted to the hospital with pneumonia.

Clinical AssessmentThe admitting physician uses an assessment tool 3) (Figure 2) that prompts her to list all the patients clinical issues, define the conditions that need to be met to discharge the patient, highlight special problems, and list any consultations, diagnostic tests, and procedures that are planned. In addition, she is prompted to anticipate factor that may delay hospital discharge and to communicate with the patients primary physician. In the parlance of project management, the assessment tool prompts the clinician to the following: Enumerate all the problems to be solved (the solved clinical problems are the deliverable)

Decide whether or not they need to be addressed as an inpatient or an outpatient(project scope) List the factor likely to constrain the project the project (risk analysis) List the tests an consults that need to be done (project logistics) Estimate the date that the patient is to be discharged (project schedule) In addition, prompts are provided so that the clinician does not reinvent the wheel when dealing with diabetes, elderly patients, andother patient groups with predictable needs. Furthermore, a prompt reminds the clinician to contact the patients primary physician to obtain additional information. This helps to further limit project scope and allows earlier discharge because a wellinformed outpatient provider will be able to deal with many issues that would have otherwise been unnecessarily investigated and treated in the inpatient setting. Moreover, achieving this level of interclinician communication is an important patient safety issue and can eliminate medical errors. The clinical assessment tool should be developed with input from the physician who will be using it, as well as the other interdisciplinary team members-such as non-physician providers, nurses, and social workers-who will translate the information into care schedule. The tool can be modified to meet the hospitals and medical staffs specific needs. For example, additional prompts can be added for specific patient populations. A nephrologist may want to incorporate data germane to chronic kidney disease, whereas a geriatrician will want additional prompts to address the needs of older patients, and so on. Moreover, the clinical assessment tool can be modified and improved on a continuous basis.

PlanningThe physician admitting a patient to the hospital is faced with the same issues as any project manager delegated the task of producing a complex deliverable. Hence, as with any project, planningis a keyto a successful outcome. In project management, one of the initial planning steps involves the development of the work breakdown structure (WBS)-a tabulation of all the tasks in the project (that is, admission).Summary tasks, which are more general, are further broken down more detailed, individual tasks.

The development of WBS provides the following benefits: Details the scope of the project (as we will see later, identifying tasks that can be done as an outpatient, and hence, eliminating these tasks from the WBS, leads to appropriate reductions in utilization, cost, and LOS). Allows the course of the project to be followed. Allows cost and schedule (LOS) estimates to be made. Allows activities to be assigned to the members of the interdisciplinary team. The anticipated duration of each summary task is based on average LOS data used by the prospective payment system, although primacy is given to the clinician`s medical judgment. As noted in the project management literature, 4) it is helpful to determine whether a WBS already exists for your project-in this case, a care map or clinical practice guideline. For example, if a care map for the diagnosis and treatment of pneumonia already exists, it can be incorporated into the WBS for that particular admission. However, patients will often remain in the hospital longer than is necessary because the care map or guideline per se does not address the issue of implementation or execution of the diagnostic/treatment plan. Moreover, clinicians often resist such tools if they are perceived as imposed on the physician or employed in a way that supplants clinical judgment or heuristics. ProjectRounds provides the clinical team with the tools necessary to plan and operationalize the clinical medicine process in a manner that is based on the clinician`s judgment, knowledge, experience, and the ability to use appropriate heuristics, formal decision-making methods, and clinical intuition. Now, to return to the patient A.B., the WBS shown in Figure 3 can be generated. The specific summary tasks and more detailed work packages attendant to each deliverable can then be more fully developedbay the admitting physician. For example, the deliverable for the patient`s chronic renal failure can be broken down into the following specific tasks; Call primary care provider (PCP) to find out baseline creatinine Correct electrolyte disorders Optimize volume status Exclude obstruction Avoid nephrotoxins Adjust medication dosages

Consider angiotensin-converting enzyme (ACE) inhibitor of patient with proteinuria Educate patient including renal replacement options if appropriate Obtain a nephrology consult

SchedulingOnce the WBS has been developed, it is necessary to create a project schedule. This can be performed by a nonphysician member of the interdisciplinary team, using readily available scheduling software. A sample hospital care project schedule is provided in Figure 4. A significant amount of judgment is involved in setting up the schedule. The tasks, or work packages, need to be small enough so as to present a detailed picture of the hospital course. However, it is necessary to avoid going intro too much detail, lest the schedule become unwieldy and impractical. If is important for the clinical team to work together closely and communicate effectively. As with and new methodology, a learning curve is to be expected, and the system will evolve and be used in a way that will allow it to be most effectively applied at a given organization and by a given set of health care providers. The key is to be consistent and standardize as much as possible but at the same time, to be flexible, given the diversity of clinical scenarios that arise.

TrackingOnce the clinician has completed the worksheet, which has been translated into a WBS and a hospital care schedule in Gantt chart format, the next step is for the team to begin evaluating and monitoring the course of the project to ensure that everything is going according to schedule. In project management terminology, this is referred to as the process of project and evaluation. 5) This process-the timely undertaking and completion of key diagnostic and therapeutic tasks- is critical to achieving high-quality care. It is, important to pay attention to any variance between where the patient is and where he or she should be in his or her hospital course. The importance of this type of variance analysis is reflected in the ORYX Initiative and the core performance measures, as developedby the joint Commission on Accreditation of Health Care Organization. 6) In project management terminology, these key clinical standards can be thought of as a tabulation of the tasks that are needed to produce key clinical deliverables, that is, high-quality care of hospital inpatients with

community-acquired pneumonia, heart failure, acute myocardial infarction, and pregnancy/related conditions. ThroughProject/Rounds, an organization can incorporate core measure into the vaseline care schedule and then track completion of data collection. A sample Gantt chart in provided in Figure 5. During interdisciplinary clinical rounds, the progress of the patients hospital care can be tracked and quantified by employing the percent complete method. The team estimates, on a per task basis, the percent of work that been completed and then enters this information into a tracking Gantt using readily available scheduling software. The software then automatically calculates the percent completion for each summary task. A hypothetical tracking Gantt for patient A.B., after one day in the hospital is shown in Figure 6. Let`s examine the tracking Gantt. We want to pay particular attention to the critical path (shown with dark bars), which, in this case, is the treatment of the patient`s pneumonia. As you can see, the official report of the chest x-ray is not yet available. The patient has completed his first day of intravenous and oral azithromycin (Zithromax). His O2 saturation was checked and was fine, and it will not be rechecked unless there is a change in his clinical status. The percent completion of the milestone task, ready for outpatient treatment is about 29%, which was derived by dividing the 4 units (days) of activity that were completed out of possible total of 14 units (days). If the chest x-ray had been officially read, the critical path would be 5/14 = 36% complete. Similarly, the chronic renal failure arm of the project is being held up because the patients physician hasn`t been contacted to ascertain the patient`s vaseline creatinine. By using the tracking Gantt, the clinical team can remain on schedule. Moreover, by bringing attention to activities that have been neglected, the tracking Gantt becomes an important tool for increasing patient safety and avoiding preventable errors. In fact, key quality indicators can be incorporated into the project Gantt as tasks. For example, under the miscellaneous summary task, additional tasks such as prevent decubiti, reevaluate need for restraints, achieve therapeutic anticoagulation, reconcile outpatient medication list with discharge medications, can be added depending on the specific clinical scenario. Failure to execute these tasks will delay hospital discharge, prolong LOS, and most importantly,

unfavorably affect quality of care and outcomes. In addition, highlighting the fact that these tasks have not been carried out can serve to avoid errors and adverse outcomes. The tracking Gantt can also be used as a dashboard which provides a concise, at-a-glance summary of the needs to be has been rendered to the patient. The members of the interdisciplinary team charged with the preparation of updated tracking Gantt charts will need to use information gathered during clinical rounds and information documented in the patient`s medical record to ensure that Gantt chart is up to date and accurate. Moreover, consideration may be given towards incorporating the actual Gantt charts intro the patient`s medical record, although this will need to be thoroughly vetted by the institution`s medical records department and medical record/forms committee.

Summary and Next stepsApplying the tenets of project management can be used to optimize the process of providing health care to hospital inpatients. ProjectRounds has been piloted on a small scale to assess the feasibility of its implementation. Physicians found the clinical assessment tool easy to use, and the author could readily translate it into a Gantt chart and then intro a tracking Gantt. Additional studies are planned to assess the effect of ProjectRounds on LOS and quality of care and other indicators. The ProjectRoundsTM trademark is owned by Darren Kaufman. M.D., M.S. Individuals, organizations, and private consultants may use the name with appropriate attribution. Darren S.Kaufamn, M.D., M.S., is chief Financial Officer and Attending Nephrologist, Port Jeff Medical Care, P.C., Port Jefferson Station, New York. Please address reprint request to Darren S. Kaufman, M.D., kauf417@optonline.net. References 1. Lewis J.P.: Fundamentals of Project Management, 2nd ed. New York City: Amacom, 2002. 2. Institute of Medicine: To Err Is Human: Building a Safer Health system. Washington, DC: National Academy Press, 1999.

3. Setrakian J.C., et al.: A physician-centered to shorten hospital stay: a pilot study. CMAJ 160: 1735-1737, 1999. 4. Kerzner H.: Project Management: A Systems Approach to Planning, Scheduling and Controlling, 7thed. New York: John Wiley and Sons, 2001. 5. Joint Commission on Accreditation of Healthcare Organizations: Performance Measurement in Health Care. http://jcaho.org/pms/index.htm (last accessed Jun. 27, 2005). This article is an exact print from the Joint Commission Journal on Quality and Patient Safety: August 2005, Volume 31, Number 8. A Morning Briefing:Setting the Stage for a Clinically and Operationally Good Day The Institute of Medicine states that organizations can improve patient safety by developing better methods of communication and by working as a team. This article discusses a study by an interdisciplinary leadership group that created a system to promote effective communication and optimize share information.Amorning briefing wad developed with specific questions heath care workers should answer before conducting their rounds in order to prevent information from being lost or forgotten.

Ergonomics in Action: the Art and Science of Limiting Patient Lifting to reduce Health Care Worker Back InjuriesHealth care workers are at a great risk of injury cause by patient lifting. The Joint Commission implicitly included the problem of worker injury cause by transferring patients among its National Patient Safety Goals for long term care, assisted living facilities, and other health care organizations. Protecting workers against back injury is an important part of Joint Commission safety standards and of the Occupational Safety and Health Administrations general duty clause. This article offers tips and resources for implementing patient lifting programs.

Collecting Performance Measurement Data to Improve SafetyThe quality of care, treatment, and services provided at a health care organization depends in part on collecting performance measurement data that allow organizations to identify problems in processes and make appropriate changes. This article provides strategies for health care organizations about what to measure and offers the resources and tools required to do so.

Unannounced Surveys: The basicsThe Joint commission will conduct all regular accreditation surveys for most types of health care organizations on an unannounced basis starting January 1, 2006 (initial surveys will continue to be conducted on an announced basis). What this change means for the organizations and how it will work in relation to the full scope of the accreditation process is the focus of this excerpt from the new JCR publication The Joint Commissions Unannounced Survey Process. This chapter answers commonly asked questions about unannounced surveys.

Video: Governance, Quality and safety: The Impact of joint Commission Accreditation of Health care DeliveryGoverning boards have the critical responsibility of representing the interest of patients and their communities when decisions have to be made. The scope of the Joint Commissions mission is similar in nature: to continuously improve the quality and safety

of care provided to the general public. This video outlines for board members how the Joint Commission helps organizations reduce risk and develop processes that maximize quality and performance. In addition to providing a background on Joint Commission standards and the survey process itself, the video specifically outlines those standards that apply to the governing board. Pay-Per-View: Publicly Reporting Comprehensive quality and Cost data Transparency in health care, including the public reporting of heath care results, is an expanding and unstoppable phenomenon. Health care systems have an opportunity to: (1) be proactive and accountable for the care they provide, (2) help patients learn more about their condition as a supplement to understanding the performance measures, and (3) use public reporting to foster process of care and outcome improvement initiatives. This article provides an overview of the first 22 months of a transparency initiative at Dartmouth-Hitchcock Medical Center (DHMC). An interdisciplinary operations group worked with the various clinical programs-both providers and patients-to identify what quality and cost measures were most desired by patients and what measures were the focus of the clinical programs internal measurement and reporting process. A variety of factors is important to the transparency initiative-senior leadersperceptions, risk management issues, resources required for the design and maintenance of initiative, and developing both methodological protocols and technical systems. November Reader Poll 2002, 2003, 2004, 2005, 2006, 2007 Joint Commission Resources, Inc.-all rights reserved.

Overview of International EMR/EHR MarketsResults from a Survey of Leading Health Care CompaniesAugust 2010

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About the studyAccenture conducted a study of leading health care software, hardware and services companies to gauge the attractiveness of eight international electronic medical record (EMR) markets of considerable size and EMR maturity. Those markets include Australia, Canada, France, Germany, Japan, The Nordics, Spain and the United Kingdom (UK). Other large marketsnamely, India and China were not studied due to conflicting opinions of overall EMR maturity. The companies surveyed have a combined market capitalization of more than $600 billion. As some of the largest software vendors, medical products companies and enterprise software providers in the world, these companies support operations in an average of more than 90 countries. To account for the leadership of several niche players, we also interviewed a number of more localized companies to refine market-specific insights. We asked survey participants a series of questions regarding the specific international EMR1 markets and discussed key trends emerging in each market. Respondents shared deep industry insights as well as general perceptions of international markets based on overall potential, market saturation, local laws and regulations, and cultural norms. This paper summarizes the insights shared and reports the results of specific survey questions. Where appropriate, we have also included secondary data to support our findings.

1. Electronic medical records (EMRs) are defined as patient treatment records, including a patients background information and history of patient care, maintained within a hospital or clinic. Electronic health records (EHRs) are defined as patient health records that include clinical data and information from multiple sources and that are maintained outside of a single hospital or clinic.

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Executive SummaryMarket forces will drive growth of global EMR markets at rates ranging from 6.6 to 9.7 percent across North America, Europe, Latin America and Asia Pacific. The global market is slated to be worth $19.7 billion in 2013: North America will experience 9.7 percent growth in its EMR market from $7.4 billion in 2010 to $9.8 billion in 2013. With 5,800 hospitals, EMR adoption is beginning to accelerate due to ARRA incentives and penalties. Asia Pacifics EMR market is expected to grow at 7.6 percent. Europe, Africa and Latin America will grow at 6.6 percent through 2013 driven by government incentives and a refresh of EMR systems. Emerging markets may be a primary growth driver globally and may have the potential to implement innovative technologies, such as cloud-based EMR solutions. Each country we analyzed represents a distinctive EMR market defined by different health care systems, competitor landscapes and local regulations and laws, requiring customized market entry strategies. Four trends will have the most impact on EMR growth: 1. Government incentives are believed by 71 percent of respondents to spur effective health IT adoption. The most significant efforts include the United States ARRA incentives and penalties and Australias $450 million e-health effort. 2. A shortage of clinical IT specialists will shift EMR maintenance and support strategies to outsourcing and cloud-based solutions, which over one-third of health organizations are using in some capacity. The shortage in Canada, as an example, requires 36,000 clinical IT workers to sustain projects through 2014. Nearly 79 percent of current clinical IT workers will require additional training experience in the next year to remain active. 3. Networking the health system across regional, national and a variety of geographic regions will offer the largest and most challenging opportunities. 4. Global economic recovery will largely impact pace of adoption and sustainability of resources.

Figure 1. Global addressable hospital-based EMR market size (USD Billions)2010 Addressable market Total $15.5B 2013E Addressable market Total $19.7B

Asia Pac $2.3

2010 2013 CAGR North America: 9.7 percent EALA: 6.6 percent AsiaPac: 7.6 percent

Asia Pac $2.9

North America $7.4 EALA $5.8 EALA $7.0

North America $9.8

Source: Accenture analysis

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IntroductionAround the world, electronic medical records (EMRs) and electronic health records (EHRs) are being implemented to improve patient care, reduce health care expenses and fundamentally change the way in which medicine is practiced. The benefits realized by EMRs in international markets are largely consistent despite vast variations in health care systems, market structures, competitive landscapes and regulatory requirements. While international expansion remains a challenge for the companies we surveyed, 71 percent view global markets as a growth opportunity in the short term (13 years) and 100 percent view global markets as an opportunity in the long term (5+ years). When asked about expansion into global markets, most respondents mentioned a standard approach: focusing first on their national markets, then identifying regional expansion opportunities or select countries in which they possess certain competitive advantages, and ultimately shifting to true global expansion into multiple markets.

Figure 2. How critical are the Global EMR markets to your companys long-term and short-term strategy?71%

57%

29%

29%

14%

Primary growth opportunity Long-term strategy Short-term strategy