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Universidade Federal De Minas Gerais Metodologia UNIVERSIDADE FEDERAL DE MINAS GERAIS Escola de Engenharia Departamento de Engenharia de Produção Luiz Carlos Nogueira Júnior METODOLOGIA PARA A SELEÇÃO DE TÉCNICAS DE PESQUISA OPERACIONAL NA ÁREA DE SAÚDE Belo Horizonte 2015 Luiz Carlos Nogueira Júnior METODOLOGIA PARA A SELEÇÃO DE TÉCNICAS DE PESQUISA OPERACIONAL NA ÁREA DE SAÚDE Tese apresentada ao Programa de Pós- Graduação em Engenharia de Produção da Universidade Federal de Minas Gerais, como requisito parcial à obtenção do título de Doutor em Engenharia de Produção. Área de Concentração: Otimização de Sistemas Logísticos e de Grande Porte. Orientador: Prof. Dr. Luiz Ricardo Pinto. Coorientadora: Profa. Dra. Leise Kelli de Oliveira. Belo Horizonte Escola de Engenharia - UFMG 2015 AGRADECIMENTOS A Deus, pelo dom da existência. Ao orientador, Professor Dr. Luiz Ricardo Pinto, pelas valiosas orientações e suporte nas horas mais complicadas, sempre com uma palavra amiga e sensata. À coorientadora, Professora Dra. Leise Kelli de Oliveira, pelo acompanhamento do trabalho, pelos grandes conselhos e por sua disponibilidade sempre generosa. Aos professores e demais funcionários do Departamento de Engenharia de Produção da Universidade Federal de Minas Gerais (UFMG), em especial aos Professores Doutores Ricardo Saraiva de Camargo e Lin Chih Cheng, pelas importantes ponderações e ensinamentos desde o início do mestrado. Agradeço em especial aos meus pais, Luiz Carlos Nogueira e Ana Lúcia Janoni Nogueira, minhas maiores referências de amor, caráter e sabedoria. A Paloma Freitas Araújo, pelo amor, carinho, respeito e parceria incondicional nestes últimos 12 anos. A Vívian Lúcia Nogueira e Isabela Janoni, pelo amor e carinho sempre por perto. Aos amigos e familiares tão queridos que estiveram sempre próximos e atentos nessa caminhada. Aos amigos de caminhada Bárbara Pinto, Celso Souza, Elisangela Martins, Karolliny Santos, Rejane Corrêa, Rivert Oliveira, Pedro Silva, Wanderson Leite e tantos outros que dividiram e tanto contribuíram para a concretização deste projeto. Aos colegas do Instituto Federal Minas Gerais (IFMG) Campus Ribeirão das Neves, ressaltando meu agradecimento ao diretor geral João Bosco de Oliveira Perdigão pela disponibilidade, à professora Jaqueline das Graças Moura Oliveira pela amizade e a Listhiane Ribeiro por me apresentar à epígrafe citada nesse trabalho. Aos professores e colegas de profissão, Luiz Filipe Trivelato, Lauro Soares de Freitas, Leonel Del Rey de Melo Filho e Marcelo Alvim Scianni, por encorajarem a busca deste sonho desde a graduação. Aos colegas do Centro Universitário Metodista Isabela Hendrix que acompanharam o início da jornada. "Conheça todas as teorias, domine todas as técnicas, mas ao tocar uma alma humana, seja apenas outra alma humana". Carl Jung. RESUMO Os sistemas de atendimento à saúde têm papel estratégico para manutenção do bem-estar social. Seja na esfera pública ou privada, há contínua preocupação em manter as diversas áreas de atendimento funcionando com qualidade, disponibilidade, com custo adequado, entre outros. Historicamente, desde a década de 1960, estudos de Pesquisa Operacional (PO) são aplicados nas diversas áreas da saúde, buscando melhorar os níveis de produtividade e eficiência, reduzindo custos, melhorando a utilização de recursos humanos e materiais. Ocorre que nem sempre esses estudos, modelagens e implementações realizados pelos especialistas em PO são bem recebidos, entendidos ou implementados pelos gestores, analistas e técnicos da área de saúde. Neste estudo, a revisão bibliográfica confirma esse problema, bem como identifica algumas das áreas mais críticas nos sistemas de saúde e os problemas mais recorrentes. Como contribuição, neste trabalho é apresentada uma metodologia que pretende nortear as partes interessadas na resolução de problemas em sistemas de saúde. A principal contribuição da proposta consiste em incluir o profissional da área de saúde no processo de tomada de decisão, buscando em conjunto com os especialistas em Pesquisa Operacional melhorar o nível de desempenho do serviço de saúde prestado. No final do trabalho é realizada análise sobre as proposições e contribuições deste estudo, bem como da perspectiva de desenvolvimentos e desdobramentos futuros. Por fim, uma implementação é realizada tomando-se como base o Sistema Médico de Emergência (SAMU) de uma grande metrópole brasileira, considerando parâmetros reais do sistema e um banco de dados consistente. O problema de localização de bases e alocação de ambulâncias é resolvido com um modelo de otimização para localização de facilidades e os cenários propostos são testados em uma modelagem via simulação à eventos discretos. Os resultados são demonstrados e discussão é realizada. Palavras-chave: Sistemas de Saúde. Problemas em Sistemas de Saúde. Técnicas de Pesquisa Operacional. Metodologia para resolução de problemas. ABSTRACT Systems for Health Assistance play a strategic role in the maintenance of social welfare. Whether in public or private sphere, there is an ongoing concern to keep the numerous areas of service working with quality, availability, appropriate cost, etc. Historically, since the 1960s, studies of Operational Research (OR) are applied in the many areas of Healthcare, seeking to improve levels of productivity and efficiency, reducing costs, improving the utilization of human and material resources. It turns out that not always these studies, models and implementations made by OR experts are well received, understood or implemented by managers, analysts and technicians of Healthcare. In this study, a broad literature review confirms this problem and identifies some of the most critical areas in healthcare systems and the most recurring problems. As an input, this paper present a methodology intended to guide participants in problem solving in Health Systems. The main role of the proposal is to include the professional of the healthcare area in the decision making process, seeking, together with experts in Operational Research, to improve the performance level of the Health Service provided. At the end of the paper is an analysis of the proposals and contributions of this study as well as the perspective of developments and future changes. An implementation is performed, based on an Emergency Medical System (EMS) in a large Brazilian capital, considering actual parameters of the system and a consistent database. The bases and ambulances location problem is solved with an optimization model for Facilities Location and the proposed scenarios are tested in a modeling through a Discrete Event Simulation. The results are shown and a discussion is held. Key words: Healthcare. Healthcare Problems. Operational Research Approach. Methodology for problem solving. LISTA DE ABREVIATURAS E SIGLAS ABC Activity-based cost AED Análise Envoltória de Dados ATS American Thoracic Societ BNDES Banco Nacional do Desenvolvimento Econômico e Social CTAS Canadian Triage & Acuity Scale DS Dinâmica de Sistemas ESI Emergency Severity Index EUA Estados Unidos da América FIFO First in – first out HIV Human imunodeficience virus IBGE Instituto Brasileiro de Geografia e Estatística IFMG Instituto Federal Minas Gerais INAMPS Instituto Nacional de Assistência Médica da Previdência Social LIFO Last in – first out MIT Massachusetts Institute of Technology NAACSOS North American Association for Computational Social and Organizational Sciences NJHA New Jersey Hospital Association OMS Organização Mundial de Saúde OPAS Organización Panamericana de la Salud PEPS Primeiro que entra – primeiro que sai PIB Produto Interno Bruto PO Pesquisa Operacional PRODABEL Empresa de Informática e Informação de Belo Horizonte S/A. RPM Frequência respiratória, pulso e resposta motora SAMU Serviço de Atendimento Móvel de Urgência SBA Simulação Baseada em Agentes SD System Dynamics SED Simulação à Eventos Discretos SIDA Síndrome da imunodeficiência adquirida SIG Sistema de Informação Geográfica SME Sistema Médico de Emergência STM Sistema de Triagem de Manchester SUS Sistema Único de Saúde TCU Tribunal de Contas da União UCLA Universidade da Califórnia - Los Angeles UEPS Último que entra – primeiro que sai UFMG Universidade Federal de Minas Gerais UPA Unidade de Pronto-Atendimento UTI Unidade de Terapia Intensiva UTM Universal Transverse Mercator VSM Value Stream Mapping WHO World Health Organization WHS World Health Statistics WSC Winter Simulation Conference LISTA DE FIGURAS FIGURA 1 - OCORRÊNCIAS DE PUBLICAÇÃO POR ANO RELACIONADAS À ÁREA DE SAÚDE - 1969 A 2014.............................................................................................................. 18 FIGURA 2 - OCORRÊNCIAS DE PUBLICAÇÃO POR DÉCADA ................................................. 19 FIGURA 3 – DETALHAMENTO DA METODOLOGIA PROPOSTA ............................................. 47 FIGURA 4 - OCORRÊNCIAS POR GRANDES ÁREAS EM SISTEMAS DE SAÚDE ......................... 52 FIGURA 5 - OCORRÊNCIAS POR PROBLEMAS EM SAÚDE AO LONGO DO TEMPO ................... 53 FIGURA 6 - FLUXO DO PROCESSO DE RESGATE ................................................................. 61 FIGURA 7 - QUANDO UTILIZAR A SIMULAÇÃO? ................................................................ 65 FIGURA 8 - MÉTODO GERAL DA SIMULAÇÃO ................................................................... 67 FIGURA 9 – METODOLOGIA DE SIMULAÇÃO .................................................................... 68 FIGURA 10 - SIMULAÇÃO BASEADA EM AGENTES ............................................................ 71 FIGURA 11 -
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