The impact of performance variability on access to healthcare: an analysis of Regional Referral Centers’ Resilience

This study aims to identify and analyze performance variability in the referral prioritization process for ambulatory care at the regional level in Rio de Janeiro state, Brazil. Exploratory cross-section study with observation sessions and semi-structured interviews, conducted in three public Regional Referral Centers (CREG). After transcription of field notes and preliminary coding, the referral process was modeled and analyzed using the Functional Resonance Analysis Method (FRAM) within the theoretical framework of Resilience Engineering. Forty-one functions were described, of which eight were critical for patient referrals. Completing the referral prioritization process depends on effectively managing variability in these eight critical functions. Among these eight functions, 13 potential instances of variability were identified, some of those being present in all three CREGs while others found in one or two CREGs. The results evidence the health system's vulnerability regarding the referral prioritization process. They show that emergent variability compels workers to devise compensation mechanisms to successfully mitigate issues that may otherwise compromise access to healthcare.