In February 2001, the Ministry of Health had begun to contemplate, through an incentive program, a significant subsidy for various types of transplants, including heart transplants. This program envisaged the distribution of a considerable amount to the Center’s team performing the operation, with the remainder being delivered to the hospital. The details were negotiated with the board of directors.
For the Cardiothoracic Surgery Center (CCT) of the University Hospitals of Coimbra (HUC), the recognition of transplants could only be good news. Since the CCT had begun performing heart transplants, the national annual average had tripled. However, Manuel Antunes, director of the CCT, after having thought extensively about the matter, continued to have doubts about whether or not he should count on this increase for the incentive program.
The CCT, currently the largest center of its specialty in the Iberian Peninsula, had begun modestly in the mid-1970s as the open-heart cardiac surgery service of the HUC. Activity levels in the first decade had been quite low, primarily for logistical reasons.
In the second decade, from 1988 onwards, the service initiated a new style under the direction of Manuel Antunes. A graduate from Lourenço Marques with a doctorate from South Africa, and possessing a strong personality, Manuel Antunes had instilled from the beginning, as his personal motto, that the reverse side of the coin of autonomy and authority was responsibility. The operational results left no doubt regarding the service’s growth. Whereas in 1988 approximately 420 surgical interventions (cardiac and pulmonary) had been performed, by 1998 the service was already performing more than 1,420 annual surgeries, tripling the interventions from ten years earlier.
By the early 1990s, the CCT of the HUC was already a reference in the field of cardiothoracic surgery. The service performed a number of interventions far exceeding the capacity for which it had been designed. The low mortality rates confirmed the quality of medical-surgical care. The Center had its specific area of interest in mitral valve repair, with success rates of around 85%, which was a practically unparalleled result at the international level.
In 1999, the Ministry of Health, through Decree-Law No. 374/99, created the integrated responsibility center (CRI). The purpose was to resume the concept of the responsibility center created in 1988. The aim was to establish an intermediate level of management between the board of directors and the hospital’s departments and services, promoting greater participation of professionals in management and more agility in decision-making processes.
The Ministry of Health decided to choose from among various hospital services the one it believed had the greatest probability of success in this management experiment. The low ratio of physician per patient treated, an annual average over the last five years of approximately 1,000 cardiac surgical interventions and 400 pulmonary interventions, the absence of a waiting list, and a positive deviation of 2,300,000 euros annually made the Cardiothoracic Surgery of the HUC a strong candidate. The decision was communicated at the end of 1998, and the service became the first CRI to be created in the country.
One of the essential instruments of the CRI was the program contract. The program contract was negotiated annually between the service and the board of directors and was integrated into the hospital’s overall budget. With the new legal framework of the CRI, the CCT gained more freedom to implement its management style.
