The Accessibility Paradox in Health Services: Global and Individual Costs

Prof. Luiz Antonio Titton, Universidade de So Paulo, Brasil Prof. Julio Araujo Carneiro da Cunha, Universidade de So Paulo, Brasil Prof. Dr. Marilson Alves Gonalves, Universidade de So Paulo, Brasil Prof. Dr. Hamilton Luiz Correa, Universidade de So Paulo, Brasil

The health organizations management has three important cornerstones that are fundamental for organizational performance: quality; accessibility and costs (AL-ASSAF, 1997). They are, hence, fundamental for its evaluation, resulting in a perspective for healthcare organizations more incisive based in performance (SHORTELL; KALUZNY, 2000). These issues related to healthcare organizations management are shown necessary before the perception that great part of healthcare professionals point out that management where they work is inefficient (VLASTARAKOS; NIKOLOPOULOS, 2007).

COSTS

The intense control over little resources on hospital-physician context demands an adequate medical service that involves decision makings based on planning and resources management (HARPER, 2002), Hospital financing limitations bring along the need to find efficient ways to manage (utilize and allocate) lack of resources (AKTAS et al., 2007). This consideration has direct effects on hospital management, since studies from several different countries (developed nations and not-developed ones) have already denoted the challenge in managing costs from lack of resources and contentions, e.g. United Kingdom (FITZGERALD, 1994; FITZGERALD; DUFOUR, 1998), Sweden (QUAYE, 1997), Canada (LOO, 1997; FITZGERALD; DUFOUR, 1998), Netherlands (SCHOLTEN; VAN DER GRINTEN, 1998), United States (GOSS; VOZIKIS, 2002; SLOAN, 2007), Oman (ABRI et al., 2006), Spain (SNCHEZ-MARTNEZ et al., 2006), France (BELLANGER; TARDIF,
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2006), Poland (KOZIERKIEWICZ et al., 2006), Turkey ( KTAS et al., 2007), Tanzand A (GILSON, 1995). This worries with researches based on costs related to health also interferes on Brazil, what is reflected when its perceived that 69% of researches from Economic Healthcare done in the country involves in some way the analysis of costs from hospital management (ANDRADE et al., 2007). In Brazil, according with Cherchiglia and Dallari (2006), these pressures for higher efficient and effectiveness in organizational activities about lack of resources happened in 1990 decade, mainly when treating about public hospitals. The authors allege that these lasts suffered with a State crisis that reduced the financial maintenance power of the State with public organizations. This decade was marked by an increasing fiscal crisis, protectionism exhaustion to national organizations and a bureaucratic and inefficient public management. Thus, its evidenced that one of the greatest issues of Brazilian hospitals relates to lack of resources. In absolute aspects, in the year of 2004, the public spending with health had a mean value of 99,89 euro per habitant (DATASUS, 2006). Adding to this, in the year of 2003, 5,32% of familiar earnings in Brazil was spent with health assistance (IBGE, 2004). So, its justified why management costs is the greatest issue on national discussion in Healthcare Management. In general aspects, managing lack of resources is still a challenge for Healthcare Management. It means that for some time, healthcare organizations from different countries are facing similar problems (HUNTER, 1996), what brings the fact that no matter what culture the nation has, similar issues are found in different healthcare organizations. In many countries, the hospital costs make pressure over healthcare management, bringing along reflections about how the resources are better destined and allocated in hospital management (KEEN et al., 1993). According to Hunter (1996), these issues related to costs contention seek for better services performance, in an effort to make hat services more sensitiveness to user (patient) and to achieve higher value for hospital invested money. Great part of these worries comes before a reality where theres lack of financial expertise for decision makings in medical management, what turns vulnerable the physician management (LLEWELLYN, 2001). Thus, its demanded a hospital management that has
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administrative and financial knowledge to deal with actual context given the essential of costs management in healthcare organizations. So, the financial management in hospitals can be defined as a set of specific techniques that are fundamental, in order to the healthcare organizations management provide entities perpetuation, reasonable remuneration to labor and capital factors and finally excellence in medical services (OLIVEIRA; GIUSTI, 2006). A financial increment or an additional rate charged to patient brings better quality in his attendance (LITVACK; BODART, 1993). It means that higher costs tend to involve greater financial quantities in attendance, what favors the existence of a positive relation between cost and quality
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It must be observed that this relation maintain in fixed costs as well as in variable ones, once investments in equipments that provides better quality in diagnosis and treatment demands higher costs. Also, theres an increase in variable costs for better quality in attendance. However, the adequate management of costs involves the precise diagnostic of patients health problems and his real needs in terms of resources to be used (AKTAS et al., 2007). It requires precise analysis that involves operational practices as well as practices relate do managerial practices. It makes costs management related to others aspects of healthcare organization, what is justified by the relation between costs to quality and organization capacity to accessibility. Therere, hence, pressures to costs reduction allied to hospital services quality increasing, that comes from government, healthcare insurance plans, community and patients (LI; BENTON, 1996). However, its not possible due to the existence of a tradeoff between security and costs, mainly what is referred to practices of material reutilization that should be used only once (SLOAN, 2007), what is also common in Brazilian hospitals and directly affects services quality i. e. its a practice that goes against security sanitary norms, but, that represents the strategy usually used by physicians that struggle against lack of resources.

QUALITY

Even before non-consensous and neither a research thought line common between researchers in definition of hospital services quality, Chassin and Galvin (1998) had already denoted the need to establish measurements over hospital quality with more scientific precision and a more standardized definition between term researches. Medical services quality have directly influence on patients quality of life (MIER et al., 2008). So, quality services have direct influence over healthcare organization main function of population life quality improvement. It brings along the so called evidence-based medicine (based com evidences and proves) which determined hospitals and their respective physicians have greater prone to develop scientific knowledge, offering healthcare services of higher quality and lesser costs (BERRY et al., 2004). Its based on the integration between clinical experience and expertise of individual physician and from better external available evidences through systematic researches done by physician (SACKETT et al., 1996). Its perceived that a higher level of quality, mainly when technology appears, can influence the costs reduction in a healthcare organization. However, its defended the principle that quality increasing requires an investment from health organization that is associated to a cost increasing. Adding to that, Porter and Teisberg (2006) what is observed is a growing increase in hospital costs in an alarming quality level. So, an increase in healthcare services quality can be linked also with a posture and organizational culture change from hospitals (DAVIES et al., 2000). From the moment that services quality and costs attentions have direct relation with hospital management, were referring to a multidisciplinary attention that involves practical clinical aspects as well as financ ial and quality management awareness. So, quality is related with financial dimension of healthcare organizations when its recognized that quality depends on management, no matter what name each one gives to it. Limits of what can be done in an organization depend on it, as matter of investments (financial or not), that can be done when expectations that will be lifted and ideally attended through quality (SCHIESARI; MALIK, 2006 b).

Quality in hospitals, according to Schiesari and Malik (2006 a), can be linked with standard conformities, right using and client satisfaction. Its considered here that quality is related to standard conformity and to right using, in a services providence that can attend the patient in a way that better satisfy him. However, its not considered as quality the patients perception related to healthcare services, as considered in some researches (e.g. ANDALEEB, 2001) or even the medical team perception of their offered job (e.g. ARNETZ, 1999). Quality is related to higher medical services practices. According to Campbell et al. (2000), medical services quality is related to its efficiency and accessibility. The efficiency is related to cliinical practices and inter-personal cares receipted. Quality definition defended here is the same developed in the 1990 decade and adopted by Institute of Medicine, in which quality is the level of healthcare service provided to individuals and populations that increases the possibility in achieving expected results in a consistent way with existent medical knowledge and practices. In this thought line, the Institute of Medicine (2001) complements that hospital quality involves measures that increases: patients security; service effectiveness according to available and existent medical knowledge; patient centralization, guaranteeing a respectful and responsible attendance according to his values and needs; wait reduction in attendance; efficiency in waste avoidance, being them material, resources, ideas or energy; attendance equity, without variations according to patients personal characteristics. This quality vision is linked with costs and its seen on studies that allege that patient can pay for a better performance (e.g. TERRIS; LIKATER, 2008; ROSE, 2008), gaining more qualified professionals and better structure and materials, as well as medications availability. It indicates that quality in services is financial linked with what can be done in a medical service. To Chassin and Galvin (1998), healthcare services quality depends also on medical team training, as well as other hospital functionaries, and on services and medical processes organization.

These elements indicate that healthcare services quality depends on investments and on higher operational cost level that makes believe that quality is positively related to hospital costs .

ACCESSIBILITY

Healthcare services quality, as mentioned, are related to accessibility capacity that service offers to its users (CAMPBELL et al., 2000). From the three cornerstones of hospital management, accessibility is the more related one to social objectives of healthcare organizations. Socially, a hospital has the function to attend the higher number of individuals as possible, in order to provide higher welfare to population. In fact, he althcare organizations can promote elements that facilitate individuals accessibility to its dependencies (DONABEDIAN, 1973). However, accessibility, as social objective, must be done under equity between individuals (SILVA; FORMIGLI, 1994), what doesnt happen when talking about private healthcare organization, given that corporative earnings are over this social function. Accessibility can be seen through the focus on patients satisfaction according to his accessibility opportunities. Accessibility can be also related to healthcare organization geographical issues, mainly when the hospital localization doesnt favors attendance maximization. So, its recognized that healthcare services localization interferes also on accessibility rate (UNGLERT et al., 1987). This discussion gains more relevancy when treating about patients from rural area (e.g. FORTNEY et al., 1999). This fact guides to other reflections, that industrialized regions, that have higher socio-economic levels than rural areas, hence, have higher accessibility to health (ADLER et al., 2008). It means that proximity is not just an explicative factor to healthcare services accessibility, but also, financial issues affect its access. The focus utilized here is related to internal and structural capacity that healthcare organization has to attend a specific quantity of patients. i.e. its a vision related to
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resources availability (inputs) and price formation from these organizations to potentially attend their patients.

ACCESSIBILITY, QUALITY AND COSTS

Researches in healthcare must contain information about medical dimension that can be related and correlated to social information (ROOS et al., 2008). It must keep sociological character when medicine is seen through sociological medicine scope (SETTLETON, 2007), this one that better justifies itself when its observed a healthcare organization through Organization Theory focus. So, understand the social reality as well as environmental and population concepts attended by hospital is fundamental to make conclusions about qualitative information lifted on research. Accessibility and quality dimensions have lot of adherence between each other because is desirable the accessibility increase with quality maintenance and vice-versa. When accessibility increase is chased, not only social issues are important. Costs reduction, especially through fixed costs dilution, is desired. It happens because in direct relation between accessibility and quality, investments in material resources also happen to quality increase, resulting in fixed costs. A healthcare organization performance boundary is the lack of financial resources available that is opposing (inverse related) to the objective of quality and accessibility maximization. The costs minimization is the main manner available to keep conditions for organization work under available resources.

Performance = f(Max Q + Max A + Min C)

When seeking for quality maximization, the consequences are the cost increase and accessibility reduction, resulting the reduction of financial resources availability. The cost increase happens through necessary investments in resources that possibly better diagnosis and treatments. These equipments, besides better performance and
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productivity, maintain significant values in immobilization. As result, its necessary the cost re-pass to user (patient), that when treating about private health, absorb it in order to gain better service perception. When observed the health public service, this cost cant be re-passed to user. In the specific case of Brazil, therere public hospitals that receive investments (very little), that usually end up being used to equipment maintenance, many of them already obsoletes, but that are absolutely necessary to hospitals (peccary) function. All citizens have the right to public assistance, without distinction, and their search for a better attendance is justified by the existence of private healthcare insurance plans. On its turn, private healthcare insurance plans attend through an agreement netwo rk within private hospitals. However, the biggest client of private hospitals is the State. Public sector contracts remunered services based on charts that pay values much lower than that practiced value on private sector. e.g. the laboratorial exam chart is not readjusted for 13 years, even with an 4% per year inflation, and the sector survives due to the investments is equipment and higher productivity.

To compensate for this, the output is to maximize the free resources generation, which is the difference between inflows and costs. Tickets are scarce and therefore the action of management focuses on reducing costs, which is one of the pillars of management.

When you reduce costs is the result of the increased accessibility, however is not desirable deterioration in the quality of service. Thus, quality acts as limiting the reduction of both costs and increased access.

Maximising the accessibility, which is access to services of health organizations, is a social objective. When you increase the capacity of numerical care, the quality serves as a limiting factor, for example, when there is considerable influx of patients in clinics to free vaccination against tropical fevers in Brazil, the level of quality of care is very disadvantaged, both in the health point of view about the perception of quality perceived by the user. A medical consultation in situations like this takes on average ten minutes, which is well below the estimated time only for a standard history (the time pattern of consultations for the SUS, Brazilian public health system, thirty minutes for the first consultation and fifteen minutes in returns). The time of doctors is a scarce resource, as far as beds, and very poorly paid, and any increase in access to care leads in crisis throughout the country. The goal of maximizing accessibility affects the cost of two ways, within an organizational and another in the level of each transaction. Under the terms of organization, the increase in the level of accessibility as a result brings the increase in total expenditures, since they are necessary investments and the level of operating costs in a higher level. This increase in costs may reflect a greater or lesser amount of free resources, depending on the level of revenue from this increase in accessibility. This dependence is linked to the ability to sum of these costs to the user, and if this is a user comes from the public system, there's no way to pass the short and medium term. Thus, while maximizing access, there is a drop in costs accompanied by a decrease in funds free. These conditions are real in both the fixed costs (which are better diluted) and the variable costs (which can be shared). For free resources, increased accessibility creates a demand fo r working capital finance the service, because both the public and the private sector service providers of pay periods with more than 30 days and is common in the public sector, in default of law, delays of up to one year, and these resources should be allocated for the financial management of the hospital.

The generation of free resources for the organisation of health can only be obtained in two ways:
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1) increasing the spin, the quantitative increase in attendance and gain in scale, or, 2) gain in margin from the reduction of unit cost of transaction.

What is presented as paradox is that the limited resources leads the administrator to decisions based on two factors: one wishes that the organization reduce their individual costs of transaction, and secondly that there is a greater training Free Resources total.

The first parameter decision leads to a desired result antagonistic to the second:

When you aim Minimize Cost, you get greater accessibility, which will generate the detention of the capital of spin, reducing the accessibility and in turn generating costs, is to finance the shortfall of cash, is to maintain accessibility. The solution found in one of the cases was investigated pass the lack of resources free to start the operation through a constant negotiation with suppliers, increasing deadlines so that the cycle of receipts could offset the financial commitments. In the case studied, suppliers are not prepared to accept the negotiation have been replaced. The equation suggests that it cancels a course in search of a static equilibrium, which is not necessarily the result of cost reduction. In this case, there is still the limiting factor is that the quality is not negatively elastic.

Final The prospect of consequences of reducing costs is the generation of increasing the availability Appeal Free generated per transaction, which will finance other activities that consume resources of the organization. These other activities can consume resources by increasing the cost (aiming to increase quality, for example), or the decrease of free generated result (when there is a need to fit working capital). This sets a paradox regarding the maximization of accessibility within the overall context of individual and organizational processes. A hospital, seek to increase the
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accessibility of its health service in its social role to seek meet as many of the people, reduce the scarce resources if it is a balance favourable to enable it to pass its cash needs for investment. The need to allocate resources for turning in medium and long term is not consistent with the increase of resources generated by trade, leaving the hospital management with an unresolved paradox in relation to planning goals, achievement of objectives and strategic alignment of the organization, it does not admit fall of quality. The study was conducted in a scenario with specific characteristics of developing countries, and new comparative studies would be needed to form a picture of how this happens in other scenarios, even if it is a paradox inherent in the stage of development.

REFERENCES

1. ABRAMS, M.; BEVILACQUA, L. Building a Leadership Infrastructure: The Next Step in the Evolution of Hospital Systems. Healthcare Strategic Management, v. 24, n 4, pp. 12-16, Abr. 2006. 2. ABRI, S. M.; WEST JR., D. J.; SPINELLI, R. J. Managing Overutilization, Quality of Care and Sustainable Health Care Outcomes in Oman. The Health Care Manager, v. 25, n 4, pp. 348-355, Out. / Dez. 2006. 3. ADLER, N.; SINGH-MANOUX, A.; SCHWARTZ, J.; STEWART, J.; MATTHEWS, K.; MARMOT, M. G. Social Status and Health: A Comparison of British Civil Servants in Whitehall- II with European and African-Americans in CARDIA. Social Science & Medicine , v. 66, n 5, pp. 1034-1045, 2008. 4. AKTAS, E.; LENGIN, F.; SAHIN, S. . A Decision Support System to Improve the Efficiency of Resource Allocation in Healthcare Management. Socio Economic Planning Sciences, v. 41, n 2, pp. 130-146, Jun. 2007. 5. AL-ASSAF, A. F. Introduction and Historical Background. In: AL-ASSAF, A. F.; SCHMELE, J. A. (Orgs). The Textbook of Total Quality in Healthcare . Boca Raton: CRC Press, 1997.
11

6. ANDALEEB, S. S. Service Quality Perceptions and Patient Satisfaction: A Study of Hospitals in a Developing Country. Social Science & Medicine , v. 52, n 9, pp. 13591370, Mai. 2001. 7. ANDRADE, E. I. G.; ACRCIO, F. A.; CHERCHIGLIA, M. L.; BELISRIO, S. A.; GUERRA JNIOR, A. A.; SZUSTER, D. A. C.; FALEIROS, D. R.; TEIXEIRA, H. V.; SILVA, G. D.; TAVEIRA, T. S. Pesquisa e Produo Cientfica em Economia da Sade no Brasil. RAP (Revista de Administrao Pblica), v. 41, n 2, pp. 211-135, Mar. / Abr. 2007. 8. ARNETZ, B. B. Self Perception of the Impact of Health Care Transformation on Quality of Care. International Journal for Quality in Health Care , v. 11, n 4, pp. 345-351, 1999. 9. BELLANGER, M. M.; TARDIF, L. Accounting and Reimbursement Schemes for Inpatient Care in France. Health Care Management Science, v. 9, n 3, pp. 295-305, Ago. 2006. 10. BERRY, L. L.; MIRABITO, A. M.; BERWICK, B. M. A Health Care Agenda for Business. MIT Sloan Management Review, v. 45, n 4, pp. 55-64, Summer 2004. 11. CAMPBELL, S. M.; ROLAND, M. O.; BUETOW, S. A. Defining Quality of Care. Social Science & Medicine , v. 51, pp. 1611-1625, 2000. 12. CHASSIN, M. R.; GALVIN, R. W. The Urgent Need to Improve Health Care Quality. Journal of the American Medical Association, v. 280, n 11, pp. 1000-1005, Set. 1998. 13. CHERCHIGLIA, M. L.; DALLARI, S. G. Tempo de Mudanas: Sobrevivncia de um Hospital Pblico. RAE-eletrnica, v. 5, n 2, Art. 18, Jul. / Dez. 2006. 14. DATASUS. IDB (Indicadores e Dados Bsicos) Brasil. 2006. Disponvel em: http://www.datasus.gov.br Acesso em: 24 Ago. 2007. 15. DAVIES, H. T. O.; NUTLEY, S. M.; MANNION, R. Organisational Culture and Quality of Health Care. Quality in Health Care , v. 9, pp. 111-119, 2000.

12

16. DONABEDIAN, A. Aspects of Medical Care Administration. Cambridge: Harvard University Press, 1973. 17. FITZGERALD, L. Moving Clinicians into Management. A Professional Challenge or Threat? Journal of Management in Medicine , v. 8, n 6, pp. 32-44, 1994. 18. _____________; DUFOUR, Y. Clinical Management as Boundary Management. A Comparative Analysis of Canadian and UK Health-Care Institutions. Journal of Management in Medicine , v. 12, n 4 / 5, pp. 199-214, 1998. 19. FORTNEY, J.; ROST, K.; ZHANG, M.; WARREN, J. The Impact of Geographic Accessibility and Quality of Depression Treatment. Medical Care , v. 37, n 9, pp. 884893, 1999. 20. GILSON, L. Management and Health Care Reform in Sub-Saharan Africa. Social Science & Medicine , v. 40, n 5, pp. 695-710, Mar. 1995. 21. GOOS, E. P.; VOZIKIS, G. S. Improving Health Care Organizational Management Through Neural Network Learning. Health Care Management Science, v. 5, n 3, pp. 221-227, Ago. 2002. 22. HARPER, P. R. A Framework for Operational Modelling of Hospital Resources. Health Care Management Science, v. 5, n 3, pp. 165-173, Ago. 2002. 23. HUNTER, D. J. The Changing Roles of the Health Care Personnel in Health and Health Care Management. Social Science & Medicine , v. 43, n 5, pp. 799-808, Set. 1996. 24. IBGE (INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATSTICA). POF 2002 / 2003 (Pesquisa de Oramento Familiar). 2004. Disponvel em: http://www.ibge.gov.br Acesso em: 24 Ago. 2007. 25. INSTITUTE OF MEDICINE. Crossing the Quality Chasm: The IOM Health Care Initiative. s/d Disponvel em: http://www.iom.edu/CMS/8089.aspx Acesso em: 16 Mar. 2008. 26. _____________. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington: National Academy Press, 2001.
13

27. KEEN, J.; BUXTON, M.; PACKWOOD, T. Doctor and Resource Management: Incentives and Goodwill. Health Policy, v. 23, n 1, pp. 71-82, Abr. 1993. 28. KOZIERKIEWICZ, A.; STAMIRSKI, M.; STYLO, W.; TRABKA, W. The Definition of Prices for Inpatient Care in Poland in the Absence of Cost Data. Health Care Management Science, v. 9, n 3, pp. 281-286, Ago. 2006. 29. LI, L. X.; BENTON, W. C. Performance Measurement Criteria in Health Care Organizations: Review and Future Research Directions. European Journal of Operational Research, v. 93, n 3, pp. 449-468, Set. 1996. 30. LITVACK, J. I.; BODART, C. User Fees Plus Quality Equals Improved Access To Health Care: Results of a Field Experiment in Cameroon. Social Science & Medicine , v. 37, n 3, pp. 369-383, 1993. 31. LLEWELLYN, S. Two-Way Windows: Clinicians as Medical Managers. Organization Studies, v. 22, n 4, pp. 593-623, 2001. 32. LOO, R. The Future of Management Training in Canadian Healthcare Organizations. Journal of Management Development, v. 16, n 9, pp. 680-689, 1997. 33. MIER, N.; ORY, M. G.; ZHAN, D.; CONKLING, M.; SHARKEY, J. R.; BURDINE, J. N. Health-Related Quality of Life Among Mexican Americans Living in Colonias at the Texas Mexico Border. Social Science & Medicine , v. 66, n 8, pp. 1760-1771, 2008. 34. OLIVEIRA, M. T. N.; GIUSTI, A. C. C. Oramento, Finanas e Custos em Administrao Hospitalar. In: GONALVES, E. L. (Org). Gesto Hospitalar. Administrando o Hospital Moderno. So Paulo: Saraiva, 2006. 35. POPE, C.; MAYS, N. Pesquisa Qualitativa na Ateno Sade . 2 Ed. Porto Alegre: Artmed, 2006. 36. PORTER, M. E.; TEISBERG, E. O. Redefining Health Care . Creating Value-Based Competition on Results.Cambridge: Harvard Business School Press, 2006. 37. QUAYE, R. K. Swedish Physicians: Perspective on the Introduction of the Stockholm Model. Journal of Management in Medicine , v. 11, n 4, pp. 246-255, 1997.
14

38. ROOS, L. L.; BROWNELL, M.; LIX, L.; ROOS, N. P.; WALLD, R.; MacWILLIAM, L. Social Science & Medicine , v. 66, n 1, pp. 117-129, 2008. 39. ROSE, J. Industry Influence in the Creation of Pay- for-Performance Quality Measures. Quality Management in Health Care , v. 17, n 1, pp. 27-34, Jan. / Mar. 2008. 40. SACKETT, D. L.; ROSENBERG, W. M. C.; GRAY, J. A. M.; HAYNES, R. B.; RICHARDSON, W. S. Evidence Based Medicine: What It Is and What It Isnt. British Medical Journal, v. 312, n 7023, pp. 71-72, 13 Jan. 1996. 41. SNCHEZ-MARTNEZ, F.; ABELLN-PERPIN, M.; MARTNEZ-PREZ, J.; PUIG-JUNOY, J. Cost Accounting and Public Reimbursement Schemes in Spanish Hospitals. Health Care Management Science, v. 9, n 3, pp. 225-232, Ago. 2006. 42. SCHIESARI, L. M. C.; MALIK, A. M. A Gesto da Qualidade nos Hospitais Brasileiros. In: GONALVES, E. L. (Org). Gesto Hospitalar. Administrando o Hospital Moderno. So Paulo: Saraiva, 2006 a. 43. _____________; _____________. Instrumentos Utilizados na Prtica Diria da Gesto da Qualidade. In: GONALVES, E. L. (Org). Gesto Hospitalar. Administrando o Hospital Moderno. So Paulo: Saraiva, 2006 b. 44. SCHOLTEN, G. R. M.; VAN DER GRINTEN, T. E. D. Between Physician and Manager: New Co-operation Models in Dutch Hospitals. Journal of Management in Medicine , v. 12, n 1, pp. 33-43, 1998. 45. SETTLETON, S. Retaining the Sociology in Medical Sociology. Social Science & Medicine , v. 65, n 12, pp. 2409-2412, 2007. 46. SHORTELL, S. M.; KALUZNY, A. D. Organization Theory and Health Services Management. In: SHORTELL, S. M.; KALUZNY, A. D. (Orgs). Health Care Management. Organization Design and Behavior. 4 Ed. Albany: Delmar, 2000. 47. SILVA, L. M. V.; FORMIGLI, V. L. A. Avaliao em Sade: Limites e Perspectivas. Cadernos de Sade Pblica, v. 10, n 1, pp. 80-91, Jan. / Mar. 1994.

15

48. SLOAN, T W. Safety-Cost Trade-offs in Medical Device Reuse: A Markov Decision . Process Model. Health Care Management Science, v. 10, n 1, pp. 81-93, Fev. 2007. 49. TERRIS, D. D.; LIKATER, D. G. Data Quality Bias: An Underrecognized Source of Misclassification in Pay-for-Performance Reporting. Quality Management in Health Care, v. 17, n 1, pp. 19-26, Jan. / Mar. 2008. 50. UNGLERT, C. V. S.; ROSENBURG, C. P.; JUNQUEIRA, C. B. Acesso aos Servios de Sade. Uma Abordagem de Geografia em Sade Pblica. Revista de Sade Pblica, v. 21, n 5, pp. 439-446, 1987. 51. VLASTARAKOS, P. V.; NIKOLOPOULOS, T. P. The Interdisciplinary Model of Hospital Administration: Do Health Professionals and Managers Look at It in the Same Way. European Journal of Public Health, pp. 1-6, 2007.

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