Viral hepatitis referral service: workflow and clinical managementAbstract
Objective To analyze the workflow performed in a viral hepatitis referral service from the perspective of clinical management.
Methods This qualitative, exploratory-descriptive research was conducted at a regional referral Testing and Counseling Center and Specialized Care Service (TCC) with a multidisciplinary team. Professionals with a higher education degree and at least six months of experience in the service were invited to participate in the research. Data collection was carried out using the focus group technique and conducted following a semi-structured script. The phonetic transcripts were analyzed thematically; the corpus was organized around the seven clinical management guidelines that guided the discussion of the findings, along with the workflow framework.
Results Advances were observed in the organization of care and adherence to the principle of integrality, with multidisciplinary care and clinical protocols. However, weaknesses in network articulation, lack of shared therapeutic plans, and gaps in quality assessment persist. Patient co-responsibility is encouraged but limited by fragmented care and low government support. Permanent education is isolated, and communication with the community is incipient, compromising the transparency and fighting against viral hepatitis in highly vulnerable contexts.
Conclusion Our results showed a good healthcare organization, but investing in interdisciplinary planning, network integration, and continuous work evaluation is necessary, requiring strengthened clinical management, coordination by the Primary Health Care, and institutional support from regional coordination.
Keywords
Human viral hepatitis; Health systems; Health work process; Health services; Health services research
Resumo
Objetivo Analisar o processo de trabalho realizado em um serviço de referência às hepatites virais na perspectiva da gestão da clínica.
Métodos Pesquisa qualitativa de natureza exploratório-descritiva foi realizada em um Centro de Testagem e Aconselhamento e Serviço de Assistência Especializada (CTA/SAE) de referência regional com equipe multiprofissional. Foram convidados a participar na pesquisa os profissionais de nível superior com seis meses de atuação no serviço (no mínimo). A coleta de dados foi realizada usando a técnica de grupo focal, sendo conduzida a partir de um roteiro semiestruturado. As falas foram transcritas e submetidas a uma análise temática; o corpus foi organizado com base nas sete diretrizes de gestão da clínica que orientaram a discussão dos achados, junto com o referencial do processo de trabalho.
Resultados Observa-se avanços na organização do cuidado e na adesão ao princípio da integralidade, com atendimento multiprofissional e protocolos clínicos. Porém, persistem fragilidades na articulação em rede, ausência de planos terapêuticos compartilhados e lacunas na avaliação da qualidade. A corresponsabilização dos pacientes/usuários é incentivada, mas limitada pela fragmentação do cuidado e pelo baixo apoio governamental. A educação permanente é isolada e a comunicação com a comunidade é incipiente, comprometendo a transparência e o enfrentamento das hepatites virais em contextos de alta vulnerabilidade.
Conclusão Os resultados mostraram organização assistencial, mas é necessário investir em planejamento interdisciplinar, integração em rede e avaliação contínua do trabalho, exigindo fortalecimento da gestão clínica, coordenação pela Atenção Primária à Saúde e apoio institucional de coordenação regional.
Descritores
Hepatite viral humana; Sistemas de saúde; Processo de trabalho em saúde; Serviços de saúde; Pesquisa sobre serviços de saúde
Resumen
Objetivo Analizar el proceso de trabajo realizado en un servicio de referencia para hepatitis virales desde la perspectiva de la gestión clínica.
Métodos Se realizó una investigación cualitativa de naturaleza exploratoria-descriptiva en un Centro de Pruebas y Asesoramiento y Servicio de Atención Especializada (CTA/SAE, por sus siglas en portugués) de referencia regional con un equipo multidisciplinario. Se invitó a participar en la investigación a profesionales con formación superior y al menos seis meses de experiencia en su trabajo. La recopilación de datos se realizó utilizando la técnica de grupo focal, a partir de un guion semiestructurado. Las declaraciones fueron transcriptas y sometidas a un análisis temático; el corpus se organizó en base a las siete directrices de gestión clínica que orientaron la discusión de los hallazgos, junto con el marco referencial del proceso de trabajo.
Resultados Se observan avances en la organización de la atención y en la adhesión al principio de integralidad, con atención multiprofesional y protocolos clínicos. Sin embargo, persisten debilidades en la articulación en red, una ausencia de planes terapéuticos compartidos y lagunas en la evaluación de calidad. Se fomenta la corresponsabilidad de los pacientes/usuarios, pero está limitada por la fragmentación de la atención y el escaso apoyo gubernamental. La educación permanente es aislada y la comunicación con la comunidad es incipiente, lo que compromete la transparencia y la lucha contra las hepatitis virales en contextos de alta vulnerabilidad.
Conclusión Los resultados mostraron una organización asistencial, pero es necesario invertir en planificación interdisciplinaria, integración en red y evaluación continua del trabajo, lo que exige el fortalecimiento de la gestión clínica, la coordinación por parte de la Atención Primaria de Salud y el apoyo institucional de la coordinación regional.
Descriptores
Hepatitis viral humana; Sistemas de salud; Proceso de trabajo en salud; Servicios de salud, Investigación en servicios de salud
Introduction
Viral hepatitis (VH) is a serious global problem, with silent infections that hinder early diagnosis and favor complications such as cirrhosis and liver cancer.(1) It was estimated that 254 million people were living with chronic hepatitis B and 50 million with chronic hepatitis C in 2022. They caused about 1.3 million deaths, making them the second leading cause of death from communicable diseases. This led the United Nations’ 2030 Agenda to propose eliminating VH as a public health threat by expanding access to testing, diagnosis, and treatment.(2,3)
In Brazil, this commitment was formalized with the launch of the Hepatitis C Elimination Plan aligned with the actions of the Unified Health System (SUS/UHS) through the National Program for the Control and Prevention of Viral Hepatitis (PNHV).(4)
Testing and Counseling Centers (TCC) and Specialized Care Services (SCS) are the main points of the public network for attention to VH, in addition to advances in the decentralization of rapid testing and treatment by Primary Health Care (PHC) services.(5)However, some weaknesses persist in the integration of services, coordination of care, and management of workflow, compromising the effectiveness of actions and health outcomes.(6)
Therefore, understanding the organization of work performed in referral services, especially in the articulation between the clinical and organizational dimensions of PHC, is fundamental.(7)In this context, clinical management is a powerful theoretical and methodological reference for integrating micro and macro-management practices, promoting the shared construction of therapeutic plans, expanding professional autonomy, and improving problem-solving capacity.(8)This approach helps to overcome the fragmentation between care and administrative dimensions, and is crucial in the care of people with VH.(9)
To improve care and promote equitable access, clinical management articulates five micromanagement technologies (clinical guidelines, health condition management, case management, clinical audit, and risk-based waiting list organization).(8)By also prioritizing the management of ends (not just means), clinical management directs attention to the Health Care Network (HCN) towards comprehensiveness centered on the needs of users and co-responsibility between professionals, managers, and users.(8,9)
Given the importance of referral services in meeting VH elimination targets, understanding the organization of work processes in these units is essential. This study was justified by the need to improve care, especially in therapeutic follow-up.(6,10,11)Thus, the present research was guided by the following question: How is the work process of healthcare professionals organized to care for people with VH in a referral service from a clinical management perspective? Therefore, the objective of the present study was to analyze the workflow in a referral service for people with viral hepatitis from the perspective of clinical managers.
Methods
This exploratory-descriptive qualitative research was conducted according to the Consolidated criteria for reporting qualitative research (COREQ) from the Equator Network.(12)
The study was conducted at a regional referral care service (TCC; in ten Municipalities) located in a health region in the State of Mato Grosso, Brazil. The above health service [TCC] has a multidisciplinary team composed of ten professionals (seven of them with a higher education), including a social worker, a nurse, a pharmacist, a clinical analyst pharmacist, a nutritionist, a clinical psychologist, and an infectious disease physician. This service is a regional reference in comprehensive care for people with VH, being responsible for the clinical monitoring and treatment of these users within the scope of the HCN.
All professionals with higher education and at least 6 months of experience in the service were invited to participate in the study; those who were absent during the data collection period were excluded. One of them did not meet the minimum service time requirement, and another was on leave (total: 5 participants).
The data were collected using the Focus Group (FG) technique in the health service rooms in the first half of 2024.(13) The approach to participants was conducted by the principal investigator, sending emails containing the credentials of the Higher Education Institution (HEI) and the research team, as well as the study’s objectives and the proposal to be developed based on the results. The invited professionals were considered key-informants because they held strategic positions within the service; their responsibilities involved organizational and managerial dimensions relevant to the security of access and comprehensive care, in line with the scope of the research.
The date for the FG session was set by consensus among participants to maximize attendance. The session was attended by a moderator (a researcher with expertise in conducting FGs) and included a secondary observer (responsible for operating the recorders, controlling the time, and recording a summary of each stage of the dialogue in a field diary). The moderator was a healthcare professional (with a Ph.D.) affiliated with the HEI, and the observer was an undergraduate student in the healthcare field.
Initially, a two-part semi-structured interview guide (developed by the researchers) was used. The first part aimed to characterize the socioeconomic and professional profile of the participants; the second one addressed the analytical dimensions related to the following: The multidisciplinary team’s work process, comprehensiveness, quality and safety of care, power sharing and co-responsibility among managers, professionals, and users, the articulation between teaching and service, educational practices aimed at the population, integration between levels of care, and transparency and accountability in defending collective interests.
The script underwent face and content validation by three experts in the subject area, who pointed out the instrument’s clarity and relevance. The questionnaire, designed to characterize the socioeconomic and professional profile, was considered suitable for the proposed objective; The analytical instrument (regarding the dimensions of clinical management) was considered relevant and consistent, ensuring its applicability in the research.
The focus group session (duration: ~1 h) was audio-recorded and supplemented with field notes, which were later integrated into the empirical data set.
The dialogue in this material has been fully transcribed with the necessary grammatical corrections for a better understanding of its content. The data were evaluated using thematic analysis to identify, analyze, and describe patterns and/or themes in the information. This technique allows for the organization and in-depth detailing of the dataset, providing a useful and flexible tool for research; given its theoretical nature, it is possible to construct a rich, detailed, and complex report.(14) In this context, the analysis corpus was segmented into seven categories; These categories guided the clinic’s management,(8)and the material was discussed based on the frameworks of the work process(15)and clinic management.(8)
The legal procedures established by Resolution 466 (guidelines and standards regulating research involving human beings) were strictly followed. The research project was approved by the Research Ethics Committee of the proposing institution (Certificate of Presentation of Ethical Appraisal (CPEA): 01481918.0.0000.5393; Opinion: 3.075.378).
Results
The sample consisted of 5 participants: a social worker, a nurse, a pharmacist, a nutritionist, and an infectious disease physician. The majority of them (80.0%) were married women (age range: 40-50 years); they had statutory employment (5; 100%), had worked at TCC for more than 5 years (3; 60%), and had postgraduate qualifications in the health field (including specialization, master’s, or doctorate; 5; 100%). Chart 1 shows the organization of the results subdivided into categories and subcategories that correspond to the clinic’s management guidelines.
Discussion
The attention given to VHs (clinical guidelines, health condition management, case management, clinical auditing, and risk-based waiting list organization) in the analyzed referral service shows the team’s efforts to offer care aligned with the principles of clinical management. However, limitations persist in the organization of the work process. They require critical reflection and the strengthening of interprofessional practice, especially through ongoing health education.(4)Progress has been observed in addressing user needs and in comprehensive care through welcoming practices, active listening, and referrals that consider the unique characteristics of each individual. This approach broadens the logic of care, valuing the bond, active listening, and the shared construction of care as the basis for a more humanized and responsive health system. At the same time, the articulation between distinct sectors and public policies to address social determinants and produce comprehensive responses to the population demands is presupposed.(8,16,17)
In the referral service, the organization of care flows, with forwarding for exams, consultations, and multidisciplinary follow-up (including users from the private network), emphasizes comprehensive care as a guideline, even though it remains centered on specialized clinical services. In this context (and from the perspective of technical and pedagogical support), fostering matrixing is important for sharing knowledge among teams, strengthening co-responsibility for care, and improving clinical practices at different points in the network.(18)
The presence of a multidisciplinary team was highlighted as an important strategy to improve the quality of care for VH. However, the challenge of effectively articulating with other points in the Health Care Network (which is fundamental to ensuring continuity and comprehensiveness of care) persists. Good practices in patient care safety (such as the use of clinical protocols, qualified listening, and reliable information to patients) were observed. However, the absence of an electronic health record, the lack of systematic quality analysis, and the scarcity of structured clinical discussions limit quality management, contributing to fragmented care. The joint and complementary action of different professional categories/groups fosters collaborative work, shared decision-making, and the production of unique therapeutic plans, thus enhancing the effectiveness and efficiency of actions in the territory.(10,15,19)
To strengthen the safety of care, investing in the computerization of services, data integration between network points, and consolidating an institutional culture focused on continuous evaluation is essential. Weak communication compromises the comprehensiveness of care, generating clinical and institutional insecurity.(20)Access to social information in medical records (available at different points in the network) promotes articulation with the social assistance network, increasing sensitivity to vulnerabilities (which go beyond the biomedical model), in addition to ensuring operational aspects.(21,22) This practice contributes to more integrated actions, centered on users, and anchored in the reality of the territory.
Therapeutic plans and follow-up strategies should be collectively built in regular spaces for dialogue (with shared planning between teams and the computerization of services in regional care contexts) to advance matrixing and co-responsibility in care. Consolidating a collaborative, horizontal, and solution-oriented network care model is essential for integrating data across network points.(10,11,15,17,22)
In VHs, care that is territorialized and centered on the users’ needs is essential, especially for vulnerable and historically made-invisible/marginalized populations. This approach strengthens ties and expands access, promoting early diagnosis, therapeutic adherence, and follow-up.(23)However, disarticulation between services compromises the quality and safety of care, generating communication failures, duplicated procedures, and discontinuity in follow-up, with the risk of adverse events and loss of connection with the health system.(6,9,24)
When there is an efficient flow of information, shared protocols, and accessible records among network points, clinical decisions become safer and more aligned with user needs. This aspect in the care of VHs is crucial, requiring continuous monitoring and prolonged adherence to treatment.(20) Lack of communication among the various levels of care compromises the continuity of therapy, favoring abandonment of follow-up and worsening the clinical picture.(11,23)Despite openness to dialogue among professionals, gaps were observed in interprofessional articulation, with a lack of clinical meetings and collaborative development of therapeutic plans, resulting in fragmented practices centered on specialties.
The persistence of a work model centered on instrumental action and fragmented into specialties prevents the consolidation of interprofessional work as a strategic tool for providing care and addressing social determinants. Services reduce their potential for comprehensiveness when subjects are not recognized as co-authors of the therapeutic process and communicative and collaborative practices are not structured, perpetuating power asymmetries and disarticulated clinical responses in the face of the complexity of the territory.(19)
The absence of shared therapeutic plans and regular spaces for clinical discussion compromises the collective construction of care and weakens interdisciplinarity.(25)Valuing different technical, popular, and user knowledge requires organizational restructuring, thus promoting teamwork, co-responsibility, and collaborative practices.(26)The lack of formal articulation limits the power of interdisciplinary teams, weakening comprehensive care, especially in VHs, whose confrontation requires integrated and sensitive strategies in contexts of high social vulnerability and low therapeutic adherence.(6,18,27)
Patient co-responsibility is a recurring practice in the care of VHs, especially when adherence to long-term treatments is necessary. Teams seek to strengthen users’ protagonism through qualified listening, recognition of autonomy, provision of clear information, and multidisciplinary support to engage them in the care process. The bond between professionals and users is central to therapeutic adherence, as trust-based relationships and dialogue favor shared decisions and greater commitment to treatment.(28,29) In this context, nurses have a strategic role in the SUS/UHS, acting in care management and coordination of the care network.(30)
The results pointed out structural weaknesses in the sharing of responsibilities among the various levels of the care network, in which PHC frequently transfers tasks to the TCC/SCS, overburdening specialized services and compromising continuity of care. The lack of integrated regional policies and the low engagement of State and Municipal entities reveal a fragmented and asymmetrical governance.
In this scenario, intersectoriality is an indispensable condition in the care context to address structural determinants and produce responses that promote co-responsibility and joint planning for comprehensive care.(10,22) The poor articulation among PHC and referral services, coupled with the absence of formal flows and instruments (such as the Individual Therapeutic Record), weakens care coordination. The lack of institutional mechanisms for co-management and co-responsibility among federated entities and network points compromises the efficiency of the SUS/UHS and deepens regional inequalities. Without strengthening the shared responsibility of the PHC in regional agreements, it tends to lose its protagonism, becoming a fragile link in the care flow.(31,32)
The mismatch between regulatory design and practice results in failures in health governance, marked by the asymmetrical distribution of responsibilities and the absence of effective support from State entities for integrated regional planning. The low capacity for technical supervision and institutional (including inter-federative) support reinforces a still compartmentalized and reactive model, in which co-responsibility is partial, coexisting with the isolation of referral services and the overload of specialized services.(4,6,10,32) This scenario compromises the continuity of care and weakens the articulation between levels of care.
Rebuilding the centrality of PHC as the coordinator of care requires agreed-upon regional protocols, governance bodies, and co-management among Municipalities and the Regional Health Office, with continuous matrix support for teams, especially in vulnerable areas. Such actions are essential to consolidate integrated clinical management, with institutional links and comprehensive care. However, the absence of a structured policy for continuing education (with guidelines and training spaces) compromises the decentralization and qualification of care for VHs. Institutionalizing knowledge management is a strategy to sustain these changes.
To effectively contribute to eliminating VHs and strengthening clinical management, it is necessary to conceive of continuing education as a continuous, critical, and reflective process, capable of developing clinical, managerial, and interprofessional competencies.(33,34)In the scenario analyzed, continuing education can drive the requalification of PHC as a coordinator of care, strengthening its technical and political capacity. Promoting a cultural and organizational transformation is necessary to reposition PHC as a protagonist in care management, articulating collaborative and integrated practices throughout the network, besides transmitting knowledge.(31)
The results indicate an emphasis on producing operational data (such as collection and service numbers) without accompanying these records with critical analysis or effectiveness indicators. The absence of clinical and social outcomes limits the service’s ability to assess the impact of its actions, compromising value-based planning and weakening the potential of lifelong learning guided by reflective work. Incorporating user-focused metrics and quality of results into routine management is essential to qualifying care and aligning management with objectives that are truly important in patients’ health and lives.(35,36)
Despite some punctual initiatives, communication with the community about VHs remains restricted to specific campaigns, with little production of educational material and limited articulation with social engagement strategies. The responsibility for disclosure falls solely on the TCC, weakening dialogue with society and compromising institutional transparency. Account rendering remains focused on quantitative data, without connection to actions of social participation or collective listening. This fragility highlights the need to strengthen public visibility and social control, which are fundamental ethical-political pillars of clinical management.(10,30)
In this sense, strengthening dialogue with the community is necessary, promoting continuous, culturally sensitive actions to broaden the protagonism of PHC and overcome a campaign-centered, punctual approach. Daily links with users favor more accessible and effective communication; they are an instrument for social participation and institutional transparency that qualify care and expand the reach of actions to prevent and promote health.(33)
However, it is important to think about how the restricted logic of analyzing health system coverage ignores the deep social and territorial asymmetries, resulting in unequal and insufficient responses to the concrete needs of the population. Then, recognizing that structural inequalities shape different rhythms, access possibilities, and care-attributed meanings is fundamental, requiring other approaches to address the existing inequalities in the territories.(17,37)
Recognizing the inherent limitations of this research is important. Conducting this study at a single regional referral center restricts generalizing the findings to other organizational and territorial contexts with distinct characteristics. In addition, the sample included the team that directly provides care; it was able to deepen the analysis despite its limitations. Despite the limitations, the findings are relevant and applicable contributions to both referral services and regional managers, also giving consistent support for improving public policies for addressing the VHs in the context of SUS/UHS.
Conclusion
The referral services Testing and Counseling Center and Specialized Assistance Service achieve important clinical management guidelines that confirm care comprehensiveness, from respect for care-protocols adherence to the ethical commitment to informing users. Structural and institutional challenges require improvement in the following areas: (1) adoption of electronic medical records and computerization, (2) institutionalization of regular spaces to discuss cases and multiprofessional care plans, (3) strengthening continuing education as an organizing axis of professional qualification, (4) creation of qualitative indicators to guide management based on clinical outcomes and user experiences, and (5) development of communication and social participation strategies to increase the transparency and legitimacy of the service. We recommend the following actions: (1) restructure the work process focusing on practices that promote comprehensiveness, care coordination, and shared responsibility among different actors in the network; (2) institutionalize regular spaces for clinical discussion; (3) strengthen Primary Health Care as the care organizer; (4) adopt computerized medical record systems for continuity of care; (5) expand interprofessional continuing education actions with matrix support; (6) expand mechanisms to assess the effectiveness of care; (7) improve communication with the community; (8) promote greater engagement of Municipal and State administrations in regional governance, and (9) align actions with the goals of eliminating viral hepatitises and collective health interests. Regarding public policies, the following actions are urgent: (1) to guide regional governance through the care pathway in an agreed perspective of shared responsibility among federative entities with a greater State presence in supervision, financing, and technical support; (2) to effect integration between levels of care, combined with the promotion of participatory and co-responsible management practices, and (3) consolidate clinical management in a broader perspective as the structuring axis of care for viral hepatitises. Considering the indispensable articulations needed to achieve universal, comprehensive, and equitable care, the following actions are necessary: (1) to deepen the production of knowledge, (2) develop studies on time and dynamics of matrixing, intersectoral strategies, and interprofessional practices involved in addressing viral hepatitises, (3) subsidize policies and interventions, (4) meet the targets set out in the 2030 Agenda, and (5) strengthen systemic responses that are more articulated, decisive, and focused on the real needs of the territories.
Acknowledgments
We thank the National Council for Scientific and Technological Development (CNPq) and the Ministry of Health/Department of HIV/AIDS, Tuberculosis, Viral Hepatitises, and Sexually-Transmitted Infections for funding this research (Process: 405761/2024-4; Call: 34/2024).
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