1. Hospital Processes

According to Azevedo et al.^[1], hospitals can be seen as gateways to the health system. In this sense, a health system could be thought of as a circuit with several entry points, where there is a suitable place to meet the needs of each type of patient. Therefore, hospitals must be open-door services for the entire population, and any measure that attempts to restrict access to healthcare is not acceptable.

2. Outpatient and Emergency

The processes related to the Outpatient and Emergency areas are extremely important, as they feed the demand that a hospital may have. It is an area that can contribute not only to the quality of care, but also to improving the patient's quality of life, as in this process situations that do not require hospitalization can be diagnosed, prevented and even treated. Its main subareas are clinical and surgical outpatient clinics, and urgent and emergency services^[2].

The screening process in hospital services must be well organized, not only in relation to physical area, material and equipment, but also with competent and sufficiently trained personnel to analyze and define priority in emergency care for patients with serious illnesses who are suffering from life-threatening, or who require immediate medical assistance^[1]}. According to Coutinho et al.^[3], the objectives of screening or risk classification are:

• Identify patients in life-threatening situations;
• Determine the most appropriate area to carry out treatment for the patient presenting to an emergency service;
• Reduce emergency service congestion, improving patient flow in treatment areas;
• Inform patients of the estimated waiting time for care, as well as the appropriate type of service they require;
• Ensure that patients who require priority care are attended to first through classification;
• Contribute information that helps define the causes of the service, as well as its complexity;
• Ensure that patients are periodically re-evaluated;
• Prioritize patient care without making a diagnosis.

The Manchester Triage System^[4], known by the acronym MTS, is a clinical risk management system, used to safely manage the flow of patients when the system has exceeded its service capacity. . The MTS has five priority levels. For each level, a number, color, name and maximum acceptable target time for medical care are defined.

Therefore, the purpose of emergency services is to offer immediate and high-quality care to patients, providing a healthcare team trained in care techniques and capable of caring for patients with a focus on improving health and quality of life^[1]. Through the Manchester Triage System, nurses are able to classify patients according to the level of urgency in which they need to be seen. Thus, reducing the risk of error on the part of attendants, prioritizing the care of patients in serious condition and improving the process as a whole.

3. Diagnosis and Treatment Exams

The processes related to the area of Diagnosis and Treatment are those related to the care provided by doctors and nurses in order to identify the health problem that affects the patient. In addition to identifying pathologies through the most varied types of exams, the objective is to define which treatment is appropriate for the patient and, depending on the case, apply it.

According to Bittar^[2], in recent decades it has been a hospital area that has received enormous technological development, contributing to improving the quality of diagnoses and treatments. Due to these advances, there has been a significant increase in the number and complexity of processes, requiring increasingly expensive technology and highly trained human resources. There are several types of exams and processes related to them. In a hospital, there are generally the following subareas: pathological anatomy, angiography/hemodynamics, blood bank, tissue bank, betatherapy, molecular biology, cardiotocography, dermatology, peritoneal dialysis, echocardiography, endoscopy, electrocardiography, electroencephalography, electromyography, ergometry, physiotherapy , speech therapy, hemodialysis, holter, lithotripsy, nuclear medicine, prostate microwave therapy, neurophysiology, ophthalmology, orthoptics, clinical pathology, pulmonology, evoked potential, chemotherapy, radiology, human reproduction, radiotherapy, rehabilitation, magnetic resonance imaging, tomography, ultrasound and urodynamics .

4. Clinical or Surgical Hospitalization

Serious cases will necessarily be hospitalized, using more complex processes than simple exams and treatments, with invasive procedures, such as intravenous infusions, which consume more hospital resources and cause a greater workload, in which the patient remains in care for a longer period of time. As a result, it is subject to conflicts and possibilities of observation of what occurs in the development of some processes. A hospital generally has the following subareas: anesthesia, surgical center, obstetric center, anesthetic recovery center, clinical-surgical, obstetric and pediatric hospitalization, neonatal unit, infectious disease unit and hospital infection control service^[2].

5. Particularities of Health Processes

According to Bittar^[2], the processes are present in all areas of a hospital, being divided between those that can be applied directly to patients and those that serve for support or service between the different areas. In addition to these, there is still a need for other processes for the infrastructure area and some of them may have a direct relationship with the patient. These processes share some aspects such as complexity, a certain diversity and a great correlation between them. Also according to Bittar^[2], it is possible to define several questions relating to hospital processes:

• For the same process, different dosages of medication may be required for different patients, in the same way as the same disease allows for different types of treatments, which can be invasive, non-invasive or just observational;
• The same disease in different patients may require a greater number and different complementary tests to be diagnosed;
• The coordination of a multidisciplinary health team is generally difficult due to the fact that there are different professional categories to make up the team. Furthermore, the diversity of training that each faculty provides ends up developing processes in different ways and at different costs, which, even though they are correct, also end up making the coordination process difficult;
• Those who order purchases in the health sector are doctors and most of the time they are unaware of the cost of the processes, causing greater expenditure than could be expected most of the time, making care unfeasible for a larger portion of the population.
• The contract between the hospital and the patient is the responsibility of the doctors who treat them, through what they place in the health records, and the information is not always complete and legible;
• The physical areas of the hospital also interfere in the processes. They are able to facilitate them when they are well organized, reducing the movement of people, reducing staff and costs. But they can also cause problems, for example, when the flow of inputs occurs incorrectly, which ends up increasing the chances of hospital infections and their consequences;
• The selection and standardization of medicines, equipment, consumables, instruments and all types of hospital supplies is made difficult by the extremely varied supply on the market and the speed with which technological development changes the products used. Delays in delivery, or products of questionable quality end up compromising the entire process;
• The constant review of hospital processes is pressured by the rapid evolution of technology;
• A large number of precision equipment is used to carry out the processes. This makes their calibration process an essential activity;
• Poor quality inputs and poorly prepared human resources can lead to repetition of work, increased costs, both financial and through loss of life or consequences left in human beings;
• Due to the large number of interactions in the execution of a process, when a non-conformity occurs, tracking the problems requires a lot of time and work from the professionals related to it;
• Urgency and emergency situations in health services require that the response time of a process being carried out is short, requiring that the actions are already described, trained and with everyone involved with their responsibilities clearly defined.
• Sometimes, the activities of a process may be in series, that is, they are executed in a sequence, or in parallel (simultaneously), requiring a lot of study to develop them;
• Internal and external influences on the development of hospital, technical or administrative processes require that quality programs be developed;
• The commitment of everyone involved is a determining factor in the success of the processes;
• Communication is the factor that makes processes viable. Therefore, routine and periodic information must be collected and disseminated every day;
• Education, training and skills are fundamental elements for the responsibility, complexity, quantity and diversity of the processes already mentioned. It is a way of ensuring quality, high productivity and low cost.

The evaluation and development of processes in the healthcare area is normally made difficult by all the factors mentioned above, as there is a great dependence on specialized and diverse labor to carry out and plan the processes. There are also issues such as technological complexity, environmental factors, differences in local and regional morbidity and mortality, institutional factors, internal and external networks of process interaction, among others, which also end up affecting evaluation and effective development. of the processes^[2].