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Gatekeeper family doctors operating a decentralized referral prioritization system: Uncovering improvements in system resilience through a grounded-based approach

Abstract:

The referral prioritization system from primary care to specialized ambulatory care in Rio de Janeiro, Brazil, was centralized until 2012. From 2012 onwards major reforms in course in the city's public health care sector restructured referral prioritization to operate from primary care, elevating primary care coverage from 7% to 70% of the population. This paper aims at describing how this organizational change reshaped the system in a large city, and how strategies used by gatekeeper physicians contribute to system resilience. The criteria used to assess resilience improvements are the Hollnagel's resilience cornerstones – Responding, Monitoring, Anticipation and Learning. The method used to disclose and describe the impacts of this organizational change to everyday work practices was semi-structured interviews with gatekeeper family physicians and the mapping of these interviews according to concept mapping guidelines. Thus the work-as-done was captured in concepts and its aspects were classified in mutually-exclusive categories. For data analysis we used the Functional Resonance Analysis Method – FRAM to depict the relations among the resilience cornerstones. The findings reveal that system decentralization paved the way for the emergence of situated strategies to cope with shortcomings at the sharp end of referral prioritization, allowing gatekeepers and primary care teams to employ and couple various adjustment maneuvers, improving overall resilience. The qualitative approach has led us to see gaps and identify support processes that are still peripheral to the formal planned assignments, pointing out innovation paths and potential future adjustments to public healthcare policies.