[Analysis of maternal deaths in Mexico occurred during 2009]. / Análisis de las muertes maternas en México ocurridas durante 2009.

BACKGROUND: Mexico reported 955 maternal deaths in 2011, with a ratio of 49 deaths per 100,000 live births. For 2015, the WHO commitment is to reduce the ratio to 22, equivalent to 415 maternal deaths. METHODS: it is a descriptive and retrospective study. In 1257 maternal deaths in 2009, we reviewed a sample of 173 records. Simple frequencies and percentages were calculated. RESULTS: direct causes of maternal death were preeclampsia-eclampsia, infection and obstetrical hemorrhage secondary to uterine atony, placental accreta and placenta previa. Fifteen patients died from abortion complications. Four patients died from extra-uterine pregnancy, because of delayed diagnosis and treatment. Indirect causes of maternal death were neoplasms, abdominal sepsis, vascular events, metabolic problems and heart disease; twenty-five patients died of atypical pneumonia and 11 more of influenza A H1N1. CONCLUSIONS: it is feasible to reduce maternal mortality by means of an adequate prenatal care, in quantity and quality of consultations, and avoiding high risk pregnancies caused by a history of obstetric factors and associated severe diseases. Influenza A H1N1 interrupted the downward trend in maternal mortality.

Introducción: en 2011 ocurrieron 955 defunciones maternas en México, 49.9 por 100 000 nacidos vivos. La meta de la Organización Mundial de la Salud para 2015 es reducir la tasa a 22.5: 560 defunciones anuales. Métodos: estudio descriptivo y retrospectivo de 1257 muertes maternas ocurridas en México durante 2009, con una muestra representativa de 173 expedientes. Se calcularon frecuencias simples y porcentajes. Resultados: las muertes maternas ocurrieron por causas directas como preeclampsia-eclampsia, infección y hemorragia obstétrica secundaria a atonía uterina, acretismo placentario y placenta previa. Quince mujeres tuvieron complicaciones por abortos. Cuatro murieron por embarazo extrauterino debido a diagnóstico y tratamiento tardíos. Las causas indirectas de la muerte materna fueron neoplasias, sepsis abdominal, eventos vasculares, problemas metabólicos y cardiopatías. Veinticinco pacientes fallecieron por neumonía atípica y 11 por influenza A H1N1. Conclusiones: es factible disminuir la mortalidad materna mediante suficientes consultas prenatales de calidad y evitar embarazos con riesgo alto por los antecedentes obstétricos y los padecimientos asociados. La influenza A H1N1 interrumpió la tendencia descendente de la mortalidad materna.

[Analysis of dengue fever deaths in Mexico: 2009]. / Defunciones por dengue en México. Análisis del año 2009.

OBJECTIVE: to describe the dengue fever mortality. METHODS: a descriptive and retrospective study including 104 files reported deaths caused by dengue fever during 2009 to march 2010, was done. RESULTS: sixty (58 %) were women and 44 (42 %) men. An increased mortality between the ages of 11 and 40 years old (47 %) was observed. Colima was a state with high incidence of cases and Jalisco had the highest mortality. Thrombocytopenia was the rule (90.4 %) and in one third of the cases platelets were below 50,000/mm(3). A quarter of cases were associated with comorbility. The initial clinical manifestations included: bleeding, hypovolemia by depletion or hemorrhage, tachycardia, paleness, depressed level of consciousness and circulatory failure. The main cause of death was hypovolemic shock or sepsis. In 42 cases, severe dengue was considered. CONCLUSIONS: an association between the severity of dengue fever and mortality was observed. The main cause of mortality was a shock state.

[The dengue fever in Mexico. Knowledge for improving the quality in health]. / El dengue en México. Conocer para mejorar la calidad de la atención.

Dengue is a systemic infectious disease of viral etiology, transmitted by Aedes mosquitoes. It causes between 50 and 100 million cases annually over 100 countries. In most of the cases it presents as influenza-like illness or undifferentiated fever and more than 500,000 patients develop dengue hemorrhagic fever. In America, dengue fever is considered the most important resurgent disease and its hemorrhagic form is becoming more relevant, especially given the steady increase in the number of deaths. The first outbreaks of dengue in America were described in 1635. Since the apparition of dengue hemorrhagic fever, in 1962, it has been considered a public health problem because half of the population lives in endemic areas. The purpose of this paper is to carry a briefly review of the epidemiology, clinical features, pathophysiology, prevention and treatment of dengue fever, as well as create recommendations in order to improve the quality of care and decrease mortality in these patients.

[Monitoring evaluation system for high-specialty hospitals]. / Sistema de evaluación por monitoría para hospitales de alta especialidad.

Hospital evaluation is a fundamental process to identify medical units' objective compliance, to analyze efficiency of resource use and allocation, institutional values and mission alignment, patient safety and quality standards, contributions to research and medical education, and the degree of coordination among medical units and the health system as a whole. We propose an evaluation system for highly specialized regional hospitals through the monitoring of performance indicators. The following are established as base thematic elements in the construction of indicators: safe facilities and equipment, financial situation, human resources management, policy management, organizational climate, clinical activity, quality and patient safety, continuity of care, patients' and providers' rights and obligations, teaching, research, social responsibility, coordination mechanisms. Monitoring refers to the planned and systematic evaluation of valid and reliable indicators, aimed at identifying problems and opportunity areas. Moreover, evaluation is a powerful tool to strengthen decision-making and accountability in medical units.

[Physician's professional retirement. Family dynamics]. / El retiro profesional del médico. Dinámica familiar.

Human beings have a natural resistance to think about their old age, both personally and professionally. Governments have targeted efforts to successfully prolong the life of the population, situation which already is a social and economic problem. "Old is a person with physical, intellectual and emotional limitations, who has a reduced autonomy and welfare, as a result of the years lived". Not everyone ages at the same age; it will depend on health, habits, physical and intellectual activity, nutritional status, vices and attitude towards life. A physician may decide not to continue exercising medicine due to: health problems, because they do not want to, because they do not feel competent, because of the risk of having to deal with a complaint or a lawsuit, to have a new life project, or because they have no patients. The options available for a doctor at the time of retirement will depend on his/her age, health status, stage of the aging process: autonomy, dependency or old age; his/her physical and mental condition, professional development, economic situation and family environment. A doctor may remain independent, join another family or seek shelter in a retirement home.

Quality of medical care and patient surgical safety: medical error, malpractice and professional liability.

BACKGROUND: over time, a significant number of definitions and concepts on quality of care have been identified. This study focuses on quality of care from the perspective of medical patients. DISCUSSION: quality of medical care includes different areas: opportunity, professional qualifications, safety, respect for ethical principles of medical practice and satisfaction with care outcomes. In this regard, at the Conamed (National Commission for Medical Arbitration), 8062 complaints have been followed, analyzed and completed between June 1996 and December 2008: in 16.8% of the complaints there were insufficient data to determine whether or not there was evidence of malpractice; 20.8% of the complaints had evidence of malpractice and in 62.4% of complaints the existence of good practice was determined according to the lex artis. Among the surgical specialties with the highest malpractice cases were the following: general surgery, gynecology, orthopedics, ophthalmology, emergency surgery, urology and traumatology. CONCLUSIONS: acknowledgment of the concept of quality of health care provides a starting point to determine the source of errors, malpractice and professional responsibility in order to resolve and prevent them. Conamed offers alternative means for conflict resolution related to physician-patient relationship by means of conciliation and arbitration, favoring patient and family, as well as the medical profession.

[Complaint analysis derived from surgical practice]. / Análisis de las quejas derivadas de las prácticas quirúrgicas.

This study reports on the analysis of medical complaints presented to the National Commission on Medical Arbitration (Comisión Nacional de Arbitraje Médico, CONAMED) between June 1996 and December 2007 to determine its magnitude and to identify the causes of safety problems in medical care. Out of 182,407 complaints presented to CONAMED, 87% were resolved by the Office of Orientation and Management. The remaining 18,443 complaints were presented to the Council Directorate. Of those cases, 48% were resolved by an agreement between the complainants and the physicians, 31% were not resolved by this method, and 3% were irresolute complaints. The highest frequency of complaints was registered in the Federal District (Distrito Federal) and the State of México (Estado de México), mainly corresponding to social security institutions and private hospitals. Among the nine most frequently involved specialties, six were surgical specialties. Malpractice was identified in 25% of all cases. The principal demands of those making complaints were the refunding of expenses in patient medical care (51%) and indemnification (40%) and, in those, the average amount of payments was 4.6 times greater. Due to the incidence of medical complaints, it was reasonable to investigate the causes and to take preventive and corrective actions required for its decrease. It was proposed to the Mexican Academy of Surgery that this organization should use their educational leadership and assume the vanguard in the dissemination and promotion of the WHO plan "Safe Surgery Saves Lives" and the implementation in Mexico of the "Surgical Safety Checklist."

Análisis de las quejas derivadas de las prácticas quirúrgicas / Complaint analysis derived from surgical practice

Se analizan los asuntos presentados ante la Comisión Nacional de Arbitraje Médico desde junio de 1996 hasta diciembre de 2007, para difundir su magnitud e identificar los problemas de seguridad en la atención médica. De 182 407 asuntos, 87 % lo resolvió el Área de Orientación y Gestión. Las restantes 18 443 quejas fueron derivadas a la Dirección de Conciliación; de ellas, en 48 % se logró la conciliación entre promoventes y médicos y en 31 % esto no fue factible; 3 % se trató de quejas irresolubles. La mayor frecuencia de quejas se registró en el Distrito Federal y Estado de México, principalmente correspondientes a instituciones de seguridad social y hospitales privados. Entre las nueve especialidades involucradas con mayor frecuencia, existieron seis quirúrgicas. Se identificó mala práctica en 25 % de los casos. Las principales pretensiones de los promoventes de las quejas fueron reintegro de los gastos erogados por atención médica en 51 % de los casos e indemnización en 40 %; en estos últimos el monto promedio de lo pagado por caso fue 4.6 veces mayor. El conocimiento de las quejas médicas permite investigar sus causas y generar acciones preventivas y correctivas, para su abatimiento. Se propone que la Academia Mexicana de Cirugía, por su liderazgo académico y docente, asuma la vanguardia en la difusión y promoción del plan “Las prácticas quirúrgicas seguras salvan vidas”, de la Organización Mundial de la Salud, y la implantación en nuestro país de la “Lista de verificación de la seguridad quirúrgica”.

This study reports on the analysis of medical complaints presented to the National Commission on Medical Arbitration (Comisión Nacional de Arbitraje Médico, CONAMED) between June 1996 and December 2007 to determine its magnitude and to identify the causes of safety problems in medical care. Out of 182,407 complaints presented to CONAMED, 87% were resolved by the Office of Orientation and Management. The remaining 18,443 complaints were presented to the Council Directorate. Of those cases, 48% were resolved by an agreement between the complainants and the physicians, 31% were not resolved by this method, and 3% were irresolute complaints. The highest frequency of complaints was registered in the Federal District (Distrito Federal) and the State of México (Estado de México), mainly corresponding to social security institutions and private hospitals. Among the nine most frequently involved specialties, six were surgical specialties. Malpractice was identified in 25% of all cases. The principal demands of those making complaints were the refunding of expenses in patient medical care (51%) and indemnification (40%) and, in those, the average amount of payments was 4.6 times greater. Due to the incidence of medical complaints, it was reasonable to investigate the causes and to take preventive and corrective actions required for its decrease. It was proposed to the Mexican Academy of Surgery that this organization should use their educational leadership and assume the vanguard in the dissemination and promotion of the WHO plan "Safe Surgery Saves Lives" and the implementation in Mexico of the "Surgical Safety Checklist."

[ISO System 9000 or evaluation of the quality of medical care]. / Sistema ISO 9000 o evaluación de la calidad de la atención médica.

Evaluation of the quality of medical care began in Mexico in 1956. This was done by reviewing the clinical files of patients. In 1984, Donabedian introduced the Theory of Systems that evaluates structure, process and results, adopted as a base in the IMSS to develop the System of Integral Evaluation and Continuous Improvement of the Quality of the Medical Care, through the identification and solution of the problems that affect quality in medical care as well as the improvements of the inefficient processes or those with low quality. The Joint Commission on Accreditation of Health Care, European Foundation for Quality Management (ETQM) and International Society for Quality in Health Care (ISQua) use a similar methodology in its evaluations. The ISO System (International Organization for Standardization) was created in 1947 to assure and to certify the quality of the production processes and to guarantee the quality of the products that were fabricated. In health institutions the ISO system is useful to certify the structure and organization, and it indicates that they are under conditions to assure the quality of medical care, but it does not guarantee that this must happen. On the other hand, faults in structure and organization may result in poor quality of care. We conclude that both systems are complementary, rather than exclusionary.

Sistema ISO 9000 o evaluación de la calidad de la atención médica / ISO System 9000 or evaluation of the quality of medical care

Evaluation of the quality of medical care began in Mexico in 1956. This was done by reviewing the clinical files of patients. In 1984, Donabedian introduced the Theory of Systems that evaluates structure, process and results, adopted as a base in the IMSS to develop the System of Integral Evaluation and Continuous Improvement of the Quality of the Medical Care, through the identification and solution of the problems that affect quality in medical care as well as the improvements of the inefficient processes or those with low quality. The Joint Commission on Accreditation of Health Care, European Foundation for Quality Management (ETQM) and International Society for Quality in Health Care (ISQua) use a similar methodology in its evaluations. The ISO System (International Organization for Standardization) was created in 1947 to assure and to certify the quality of the production processes and to guarantee the quality of the products that were fabricated. In health institutions the ISO system is useful to certify the structure and organization, and it indicates that they are under conditions to assure the quality of medical care, but it does not guarantee that this must happen. On the other hand, faults in structure and organization may result in poor quality of care. We conclude that both systems are complementary, rather than exclusionary.

El error médico: eventos adversos / Medical error: adverse events

En la actualidad, la seguridad de los pacientes durante el proceso de atención médica ha alcanzado una relevancia prioritaria, determinando la necesidad urgente de garantizarles que sus necesidades de salud se vean satisfechas en las mejores condiciones posibles, sin verse complicadas por eventos adversos ocurridos durante el proceso de la atención. En el presente documento se proponen definiciones de los términos error médico, criterio médico, evento adverso y evento centinela, a fin de manejar conceptos semejantes. Se presenta la secuencia de eventos que puede conducir a la toma de una decisión correcta o incorrecta, el error consecuente y su derivación hacia un evento adverso, con daño para el paciente. Se hace énfasis en que la práctica médica está inmersa en un paradigma biológico impredecible, adaptativo, reactivo y creativo, a diferencia de las ciencias físico-matemáticas, que están dentro de un paradigma sujeto a leyes matemáticas, predecible y estructurado. Como consecuencia de esto, en la práctica médica cada paciente es una situación inédita que requiere de todos los conocimientos, habilidades y experiencias, para satisfacer sus necesidades de salud particulares, especialmente en situaciones críticas. Se proponen los medios para protegerse del error médico, incluyendo las guías clínicas, la medicina basada en evidencias, el mantenimiento de la competencia profesional a través de capacitación y actualización continuas, la relación médico-paciente estrecha, el estudio clínico completo y los registros escrupulosos en el expediente clínico. Como consecuencia de los errores médicos, con frecuencia se da lugar a eventos adversos que representan daño para la salud del paciente, o eventos centinela, que pueden tener consecuencias graves para la salud, la integridad o la vida del paciente. Se hace énfasis en que los eventos adversos pueden presentarse sin que esté de por medio un error médico, sino por fallas en la estructura y en los sistemas, incluyendo...

At the present time, care the patients safety during across the process of health is a priority target and determine the urgent necessity, to guarantee the satisfaction of their health needs, on best conditions as possible as it is, without complications for adverse events occurring in the medical attention. This paper purpose definition of different concepts like medical error, medical criteria, adverse and sentinel event, in order to define these concepts. Also try to show the sequence of events for a correct or incorrect medical decision, the consequent mistake and the possibility to produce an adverse event, with patient's damage. An important goal is that the medical practice is immersing in a biological paradigm, define like unpredictable, suitable, reactive and creative; very different to the exact science that has a predictable and structured paradigm, supported in mathematical rules. In the medical practice, each patient is an inedited situation and required all the knowledge, skills and experience in order to satisfy specific health needs, particularly in critical moments. The way for protect from the occurrence of medical error include the clinical practices guidelines, evidence-based medicine, the maintenance of professional competences by the continuous training, the close medical-patient relationship, integral approach of the illness and scrupulous data at the clinical record. In consequence, very often medical errors produce adverse events with damage of patients, or sentinel events with serious consequences of health, integrity or patient's life. Is important to say that the adverse events could be appear even without a medical error, just for failures in structural and systems issues, including resources and it's maintaining, organizational variables, communication, human resources, training programs, process without standardization, failures an supervision or control phases. This paper shows current adverse and sentinel events, and...

[Medical error: adverse events]. / El error médico. Eventos adversos.

At the present time, care the patients safety during across the process of health is a priority target and determine the urgent necessity, to guarantee the satisfaction of their health needs, on best conditions as possible as it is, without complications for adverse events occurring in the medical attention. This paper purpose definition of different concepts like medical error, medical criteria, adverse and sentinel event, in order to define these concepts. Also try to show the sequence of events for a correct or incorrect medical decision, the consequent mistake and the possibility to produce an adverse event, with patient's damage. An important goal is that the medical practice is immersing in a biological paradigm, define like unpredictable, suitable, reactive and creative; very different to the exact science that has a predictable and structured paradigm, supported in mathematical rules. In the medical practice, each patient is an inedited situation and required all the knowledge, skills and experience in order to satisfy specific health needs, particularly in critical moments. The way for protect from the occurrence of medical error include the clinical practices guidelines, evidence-based medicine, the maintenance of professional competences by the continuous training, the close medical-patient relationship, integral approach of the illness and scrupulous data at the clinical record. In consequence, very often medical errors produce adverse events with damage of patients, or sentinel events with serious consequences of health, integrity or patient's life. Is important to say that the adverse events could be appear even without a medical error, just for failures in structural and systems issues, including resources and it's maintaining, organizational variables, communication, human resources, training programs, process without standardization, failures an supervision or control phases. This paper shows current adverse and sentinel events, and distinguish between the possibility of its measurement with good and standardized register systems.

[Ethical principles in medical practice]. / Principios éticos de la práctica médica.

In the present work, we present an analysis of ethics in the practice of medicine, as a fundamental element of the quality of medical care. We present a brief review of factors related to the development of ethics. In this paper we have shown different institutional and societal conditions for the definition and promotion of ethics. We present a conceptual analysis of the quality of medical care and how ethics interplays with the care given by medical practitioners and how that combination of quality medical care and adherence to ethical principles are used to solve health problems, with a high-degree of satisfaction to both patients and their families. Before entering into the conceptualization of each of the ethical principles of medical practice, the concepts of morality, ethics, bioethics, medical ethics, and ethical deontology are defined. We continue with the proposal of ten ethical principles of medical practice that include charity, fairness, autonomy, confidentiality, respect, dignity, solidarity, honesty, loyalty, and justice, and the concept of each of them, as well as the precepts that each principle contains.

Plan general de atención a la salud de los adultos de 65 años y mayores por parte del internista / General plan of health care of 65 year and older people by internist

Antecedentes: no existe un plan diseñado para promover la salud en los individuos mayores de 65 años de edad. Objetivos: identificar las enfermedades que con más frecuencia afectan a las personas mayores de 65 años de edad y sistematizar la atención de esta población mediante el autocuidado y el fomento a la salud, la prevención primaria, secundaria y terciaria oportunas y efectivas, a fin de mejorar el nivel de salud, la calidad de vida y abatir los costos de su atención. Material y métodos: a través de un estudio efectuado durante un año sobre la demanda de atención en el IMSS1 se identificaron los principales motivos de consulta de medicina familiar, especialidades y urgencias, hospitalización y cirugía, así como las causas de defunción. Como resultado del análisis se dilucidaron las enfermedades que con más frecuencia afectan a los individuos mayores de 65 años de edad. Resultados: los problemas de salud de los sujetos mayores de 65 años de edad son: diabetes mellitus, hipertensión arterial, obesidad, hiperlipidemias, aterosclerosis, hiperplasia prostática, trastornos de la estática perineal, infección de las vías urinarias, hepatitis crónica por alcoholismo, virus B o C y bronquitis agudas. Asimismo, las principales enfermedades crónicas identificadas son: complicaciones de la aterosclerosis y de la diabetes mellitus, cirrosis hepática, sida y bronquitis crónica. Conclusiones: se propone un plan para manejar cada una de las enfermedades o alteraciones detectadas desde las etapas de menor complejidad, a través de inmunizaciones, de la identificación temprana, de la detección oportuna, de la modificación de los factores de riesgo y de la vigilancia estrecha de los pacientes con antecedentes familiares de padecimientos potencialmente hereditarios. Cuando el individuo sufre enfermedades o alteraciones preexistentes, es necesario tomar medidas de control que impidan su progreso hacia la cronicidad o a estados de daño irreversible, a etapas de mayor gravedad o al desarrollo de complicaciones. En la etapa de cronicidad únicamente se podrá ofrecer control periódico, a fin de detener la evolución de las enfermedades hacia condiciones discapacitantes y a la muerte.

Polifarmacia en el anciano / Polypharmacy in elderly

Los enfermos mayores de 65 años de edad representan el grupo que más fármacos consume. La mayoría de los pacientes ancianos toman múltiples medicamentos como consecuencia de una variedad de condiciones médicas concurrentes. El presente artículo revisa los principales factores relacionados con el paciente y con el médico, que incrementan los efectos adversos de las drogas, así como algunas medidas de prevención a fin de minimizar el potencial de los efectos colaterales de varios esquemas terapéuticos que reciben los pacientes ancianos con afecciones crónicas.

Sistema para evaluación integral de la calidad de la atención en bancos de sangre / Integral evaluation system for quality of attention at blood banks

Se presenta un método para evaluación de la calidad de la atención en los bancos de sangre, como instrumento para mejorarla mediante la identificación y solución de problemas y procesos ineficientes o de baja calidad. El estudio se realizó en siete bancos centrales de sangre del Instituto Mexicano de Seguro Social, clasificando los problemas de acuerdo con el nivel de responsabilidad para la solución y concepto evaluado. El avance en la solución y mejora de los procesos ineficientes o de baja calidad fue en forma global de 47.6 por ciento; y el de aquéllos cuya solución correspondía exclusivamente a los bancos de sangre fue de 70.9 por ciento (nivel de confianza de 99 por ciento). Se concluye que el sistema de evaluación propuesto es útil para mejorar permanentemente la calidad de la atención, y tomando en cuenta las características de los mismos puede aplicarse a otros bancos de sangre

Demanda de atención médica en el IMSS por derechohabientes de 65 años y mayores: análisis epidemiológico / Demand for medical attention at the Mexican Institute of Social Segurity (IMSS) by membership reghts holders of 65 years of age and older: epidemiological analysis

Se presenta un análisis a un año, de las principales causas de demanda de servicio médico en la población derechohabiente adscrita a médico familiar en el Instituto Mexicano del Seguro Social, según el nivel de atención, las principales causas de defunción y su frecuencia. Para ello se dividió a la población derechohabiente en dos grupos: pacientes de 65 años o más, y menores de 65 años. Se identificó el número de casos y la cifra porcentual de cada padecimiento en cada uno de estos grupos con relación al total; se determinó la frecuencia de los padecimientos por cada 100 derechohabientes usuarios y el riesgo relativo para demandar atención. Se observó que el grupo de 65 años o más representa 8.38 por ciento de la población derechohabiente adscrita a médico familiar y al analizar la demanda por cada 100 derechohabientes de dicho grupo el riesgo relativo para demandar atención es superior en consulta externa de medicina familiar, consulta de especialidades y egresos hospitalarios; las defunciones fueron 10.93/1 más frecuentes. Este riesgo es muy superior en consulta externa de medicina familiar en cuanto a padecimientos como osteoartrosis, hipertensión arterial y diabetes mellitus. Con base en la identificación de las principales causas de morbilidad y mortalidad, se presentan propuestas de programas para mejorar el nivel de salud de la población de adultos mayores, mediante educación y capacitación para la salud, autocuidado, detección oportuna, prevención, atención y rehabilitación oportuna de los padecimientos que generan mayor demanda. También se proponen indicadores para la evaluación de los programas aludidos.

Programa de mejoramiento continuo: resultados en 42 unidades médicas del tercer nivel / Program of continous improvement: results of 42 tertiary-level medical units

Se presenta una metodología para evaluar la calidad de la atención otorgada por 42 unidades médicas del tercer nivel del Instituto Mexicano del Seguro Social, entre 1992 y 1993; así como los resultados del seguimiento a los avances logrados un año después. La evaluación se realizó en forma integral, sistemática y procesal, incluyendo recursos físicos, personal, insumos, organización, proceso de la atención, resultados y satisfacción; abarcó los procesos de urgencias o admisión continua _según el caso_, consulta externa, hospitalización, cirugía, auxiliares de diagnóstico y tratamiento, ingeniería biomédica y procesos generales. En la primera visita se identificaron los problemas y los procedimientos ineficientes o con resultados de baja calidad, que estaban afectando negativamente la prestación de la atención médica. Con participación de los responsables en los niveles operativo y directivo se determinó la mejor opción para solucionarlos, y se establecieron compromisos para ello. Los problemas fueron registrados y clasificados por proceso, capítulo de la evaluación, unidad, y clasificados conforme al nivel de responsabilidad para resolverlos (unidad, delegación y nivel central). Un año después se realizó una visita de seguimiento para determinar el grado de avance en las soluciones: la superación de las expectativas representó un logro; 100 por ciento significó problema resuelto; entre 1 y 99 por ciento, parcialmente resuelto. Los resultados de este estudio fueron comparados con los obtenidos en otro de naturaleza similar efectuado entre 1983 y 1984, encontrando que los avances alcanzados nueve años después en la solución de problemas fueron significativamente menores. Se concluye que la evaluación integral, sistemática y procesal de las unidades médicas es un procedimiento útil para la incorporación a la mejora continua de la calidad y eficiencia de las unidades médicas