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Aims
General Objective
To identify the factors that prevent the creation and impulse of the organisational learning for the control, managing and alertness of the hospital infections in the committees of the social Enterprises of the State, assigned to the Secretariat of Health of Bogotá D.C.
Specific aims
To identify the type of approach of organisational learning that prevails in the committees of Alertness of Hospital Infections and its consequence in the creation and impulse of the organisational learning.
Toidentify the organisational factors of the committees of alertness of intra-hospitable infections that prevents the creation and impulse of the organisational learning.
They were obtained 119 surveys of which four were eliminated in the process of purification for having less than 80 % of the totality of answered articles, 3 of these were corresponding to the same Entity, for previous the analysis process is based on 115 surveys of 14 organizations and the Institution of services Carlos Lleras Camargo
The measurement scale is a type Likert, it took as a reference to ratify with the mode of the distributions of frequency, in order to determine, this way, the direction or trend of the answers in the articles and the correlation was established among the mentioned scores. This correlation allows showing the relevancy of the dimension as analysis variable in the context of the organisational learning. It was used the procedure of Analysis of Variance - ANOVA - to a route, where the dimension score was taken as a dependent variable and as factor, the hospitals.
The statistical procedures were carried out using the statistical package SPSS.1
Introduction
This presentation paper makes a part of the work of investigation that is developed inside the line of investigation in management of the knowledge, in the project Organisational Learning. The change which the health sector has faced in the last 11 years in Colombia have sought to solve a situation of inefficiency, inequity, low coverage and bad quality in the service prestation, as well as an adoption of measurements that were answering to the new needs of the surroundings; conditions that have brought themselves the closing, merger or restructuring of health service prestation entities that have not demonstrated advances towards the consolidation of an auto-sustainable, efficient enterprise.
The theory of knowledge management determines that the hospitals are companies based on the knowledge, since their processes are determined in basic aims and specific actions, as well as in a structure in which each one is responsible in the achievement of an aim, and they establish the one who depends of whom as for a specific information, composed in mostly for specialists who must mark the course and organized feedback proceeding from their colleagues, clients and head offices. (Drucker, 2000: 2,3).
Description of the Problem
The intra-hospitable infections are a negative event of Public Health, with a high degree of externality, whose control process, managing and alertness is implicit to the quality guarantee of the services offered by the health service Institutions, either public or private.
This process, for being clearly institutional, must be anticipated, controlled, handled and monitored, as it is faced to a great number of organisational barriers, one of these, is the absence of learning. This organisational learning is not simply the interpretation of information or the systematical summary of these, but in the applicability for all the specialists based on clear, common and simple aims, which result in concrete actions.
In spite of the fact that the literature refers to the hospitals as companies of learning, even in the area of the intra-hospitable infections there is much for exploring, learning, understanding and to answer; therefore this work seeks to give response to the following question problem: what organisational factors of the committees of hospital Infections of the Social Enterprises of the State assigned to the Secretariat of Health of Bogotá affect in the creation and impulse of the organisational learning for the control, managing and alertness of the Intra-hospitable Infections?
Conceptual frame
Sustainability
For the group of managerial sustainability of the University of El Rosario, a lasting company is that one which through the time presents financial top results adapts its managing to the intensity of the market forces, focuses in not exploited spaces and does a detailed study of its competitors, designing and executing productively the value chain.
It is also the one that obtains performances conductive to morbile conditions that impede its profitable growth and that can come to tatanic conditions.
Organisational Knowledge
We understand the knowledge in the company as the intellectual product of the persons, generated by the association that is done among the data and information provided by the facts, inside the specific context of a certain stage; which are used as current facts that being combined with similar elements before stored in their mind and in the means of information of the company, allows them to take the necessary actions to face the problem that they must solve (Quintero: 2003).
Management of the knowledge
The ideal functioning of the learning system is determined to the form in which the interaction is managed among the learning levels and the knowledge flows, in order to guarantee that it turns into a value source; it refers to the mechanisms that guide and facilitate the excellence of the conformation and maintenance of the learning system.
Organisational Learning
Organisational Learning is the capacity that the organisations have to create, to organise and try information, in order to generate new knowledge, which allows them to develop new capacities, to design new products and services, to increase the existing offer and to improve the processes; it is given through the renovation of the structures and mental schemes and the incorporation and .and the incorporation and production of new learning and knowledge in the different levels. ((Argyris, (1999) Choo (2003 - 1-29); Etkin, (1999, 27 - 31).).
For Peluffo M, mentioning to Yoguei the learning has a meaning dependent on the learning level, in this way he determines that the learning:
Model of organisational learning in the sector health
It is considered the organisation as a system where the learning processes are given among its different levels: individual, team and the organization itself, each of which possess a stock of knowledge.
The type of knowledge that is transferred among the levels is dependent on the direction of its destiny, this way the knowledge that is transferred from the organisation to the team and/or individual, is an already existing knowledge inside the organization, result of past experiences.
Inversely the knowledge is of exploratory type, solutions search to emergent problems or compartment of knowledge that each of the members possesses.
It is joined the model of common knowledge, described by Dixon, which, allows to disintegrate the transformation of the experience in knowledge, given in each of the levels of the organization. So Dixon (2001-20) disintegrates in the model of common knowledge, the transformation of the experience in knowledge, given in each of the organisation levels (individual, group, and organisation) in the following steps:
Components of the model:
Supplier Star of Value: It is in the entrance, the company acts as client of the supplier, and his aptitude to generate knowledge contributes of significant form to the capacity of value creation of the company.Star of value of the client: It is in the exit. The contact with the clients produces new ideas and stimuli for the generative processes.
Sources of the organisational learning
According to Garzon (2004: 16) ten sources of organisational learning have been identified, they are: History of learning; shared
Suppositions, Experience, Experimentation, The clients, The suppliers, The technology, The practitioners, The crises, The observation and reflection, The systems of information.
Learning levels
It refers to levels, the hierarchic subgroups of learning that include the organisation, are like this : the individual, the work teams, the organisation (ESEs) and the inter-organization (SDS).
Flow of knowledge
The flow of knowledge is endowed with a double committed: 1. To propitiate the amplification and variation of the knowledge and 2. To discover the knowledge that exists in the organization and feed it back, opening the door to the search of the flexibility by means of the generation and assimilation of new knowledges (exploration) and at the same time to the search of the efficiency by means of the distribution and utilization of available knowledge inside the organization (exploitation).
Organizational Factors that Influence in the Creation of Organizational Learning
The tangible and intangible factors form a dynamic tension, which in general is not identified and is not understood exactly. The production and services systems are forced to be centered in objective or tangible measures and, in agreement with this, the systems of stimulus of the organizations depend in great part on measurable results, although the people are vital part of any system, specially work systems by team, they are the intangible ones, those that promote the effective performance of the workers. Cutcher - Gershenfeld et al (2000:73).
Tangible factors the structure
The behavior of the man in his work is projected in the structure to which he belongs. According to Méndez (2003) it performs basic tasks such as to rationalize the organization so that the objectives are fulfilled. It identifies the dynamics on which the organization operates in terms of the power and the decision making from the hierarchical structuring, authority, centralization and coordination.
The systems and technologies of the information
This is the technology or tools that facilitate the discovery, the retention, the distribution or the transformation of the information and the knowledge, in a useful language and with an access and fast interchange (Prieto).
The strategy
The strategy is the definition of what a particular organizational system hopes to do in the future, defined in processes oriented to conceive and to adopt a shared vision, so that all the members of the organization reach a common interest on what they want to obtain and on the form in which they can obtain it.
Intangible factors
The intangible elements are an integral part for the system operation; it is very difficult to develop the team spirit, whose members can develop interdependence, confidence and shared knowledge, but their experience is unique with respect to a work center, context and specific group of people. (Cutcher - Gershenfeld and company 2000 - 81) Some intangible elements, described by these authors are: participation in the design of the work organization, property, confidence, pride, knowledge creation, information flow, interdependence.
The symbiosis refers to the commitment with an idea, an experience, a concept or a human being, In the development of shared tacit knowledge, the challenge for the individuals that integrate a microcommunity is to come to the symbiosis with the experience, the perspective and the concepts of the others. Krogh et al (2001- 93).
Some important intangible factors for the generation of interest in the knowledge creation:
Management of the knowledge
The optimal operation of the learning system is conditional to the form in which the interaction between the learning levels and the flows of knowledge is managed, with the purpose of guaranteeing that it becomes a value source; this refers to the mechanisms that guide and facilitate the excellence of the conformation and maintenance of the learning system.
Prieto and Rivera (2004: 5), reveal that the numerous initiatives that appear in management of the knowledge, can be put together in two great expositions:
1. Technical - Structural Approach:
The vision of the learning predominates and its management as something objective and centered in the manipulation of the information. Thus the management of the knowledge is synonymous of design and structured implementation of technologies and other enterprise processes, oriented to the processing and the efficient administration of the information within the organization, by means of the design and the disposition of systems or tangible elements of communication.
2. Approach of the Behavior:
In this approach, the linking with the social and human behavior is important, so that the human being is the central axis.
Factors such as the transformation of a process, a group composition, the source of intelligence or a variation in the organizational confidence levels, can alter the process of knowledge creation. The individual contributions of the people in a group have an effect on the collective product, and if one of these people is absent or if a new member joins the group, it changes the nature of the virtual knowledge, as well as the knowledge that is derived from this. Cutcher - Gershenfeld and company (2000: 67 - 68)
1. Method’s and material’s
1.1. Descriptive Study
The descriptive study delimits the facts that shape the investigation an s e , and identifies characteristics of the universe.
1.3. Information Sources
Primary Source
The technique used in this work is the survey.
Secondary Source
Compilation of information obtained from the an s e of documents, books, thesis realized on the an s e d investigation.
1.4. Population an s e d study
The universe of the studied population is 22 State social Enterprises assigned to the Secretariat of Health of Bogota D.C. The population objects of study are the committees of intra-hospitable Infections of 22 ESEs (State Social Enterprises) assigned to the SDS (Secretariat of Health of Bogota), which includes a whole of 220 persons.
1.5. Variables definition
The definition of the variables was realized under the an s e organisational learning elaborated by the investigators and they are: organisational learning sources; organisational learning levels; organisational factors that influence the learning; approach of the knowledge management in the ESEs; knowledge an s e da.
1.6. Investigation Instrument
It was used the survey, developed under the methodology of a scale construction type Likert. This one is a type of adding scale that corresponds, according to Padua (1987: 163) mentioned in Garzon (2000: 188), to an ordinal measurement level.
1.7. Instrument pilot test
A pilot test was carried out to the instrument in two Health entities that didn’t fit with the criteria of incorporation, in whole it was answered by 17 members of the committee of infections of these institutions.
1.8. an s e d the pilot test
Items selection for the survey form
It was an s e dan instrument consisted of 114 articles in a Likert scale with the aim of measuring the creation and impulse of the organisational factor. A detailed analysis of this article allowed determining the above mentioned factors. Plazas (3) (2005).
With this first step, it is set from a pilot survey to evaluate the relevancy of the an s that involve the test, looking first of all that they are determinants of the factors and therefore important in the evaluation of the aims.
The an s were constructed following the conceptual frame, the relevancy of every item in the test, whichdepend largely in its formulation and of the investigator knowledge and experience.
Some articles of those, which presented correlation below 0.5, were included in the instrument since it was believed that their importance was more relevant an the statistical result.
1. Results of analysis
2.1. Process information compilation
For the compilation of the information it was carried out a meeting with members of the committees of intrahospitable infections of 22 ESEs assigned to the SDS, meeting in which 11 correspondents took part, to whom the project was shown and they agreed in the accomplishment of the surveys in each of their entities.
The surveys were realized personally to each of the members of the committee of intrahospitable infections. At the end of the information compilation there were obtained 119 surveys of 14 State Social Enterprises and the Health Institution Carlos Lleras Camargo, all assigned to the Distrital Secretariat of Health.
Of 119 tabulated surveys, 4 were eliminated in the process of purification for having less than 80% of the totality of answered items, 3 of these corresponded to the same entity. The analysis process is based on 115 surveys of 15 Public Health entities assigned to the Distrital Secretariat of Health. The calculations of the population sample corresponded to 135 surveys, goal that was fulfilled in 85 % in a period of two months.
2.2. Statistical analysis
For the results analysis effects it was followed the following plan of statistical analysis:
The first part of the analysis was realized considering the dimensions of each one of the evaluation areas related to the organisational learning.
In order to assure the contribution of the average score of the dimension with regard to the whole, the correlation was established among) those scores. This correlation allows showing the hospitals. Because of this, it was in use the procedure of Variance Analysis - ANOVA - to a route, where the score of the dimension took as a dependent variable and as factor the hospitals.
For effects of evaluating which hospitals differ among them it was used the method of Dunet's(4) multiple comparisons in which the Hospital Carlos Lleras Camargo was taken as a reference. The significance level to decide if the equality between two hospitals is true took below 5 %.
The measurement scale used for the evaluation of the organisational learning is a scale Likert, and that is an ordinal scale. The analysis bases on the score average and that these averages are influenced by the extreme values, (1 and 5 in the ordinal scale), it took as a reference to ratify with the mode of the frequency distributions this way to determine the direction or trend of the answers in the items.
The previous statistical procedures were realized using the statistical package SPSS.(5)
2.3. Characterization of the sample
The public network in health is distributed by sectors of the following way:
1). Red del Norte, Hospital Simón Bolívar, Engativá, Usaquén, Chapinero y Suba; 2). Red de Sur Occidente, Hospitales Pablo VI Bosa, Sur, Bosa, Fontibón y Kennedy; 3). Red Centro Oriente, ESE San Cristóbal, Centro Oriente, San Blas, La Victoria y Santa Clara y 4). Red del Sur, Hospitales de Úsme, Tunjuelito, Rafael Uribe, Vista Hermosa, Nazareth, Meissen y El Tunal.
Distributed by attention levels, thus: five of the third level, seven of second and ten of first level, these last ones composed by Centros de Atención Médica Inmediata (CAMIS), Unidades Primarias de Atención (UPAS) and Unidades Básicas de Atención (UBAS), with a total of 144 points of attention in health in all the levels of attention. (SDS 2003)
The population sample conformed for 115 persons members of the committee of hospital infections of 14 State Social Enterprises and of the Health Institution Carlos Lleras Camargo, with a distribution for company and professional group described in the Chart number 1.
Chart N° 1 Population Distribution for company and professional group
| Nº | Entity | PROFESSIONAL GROUP | ||||
| 1* | 2** | 3*** | 4**** | 5***** | ||
| 1 | Tunjuelito | 2 | 1 | 2 | 0 | 1 |
| 2 | Nazareth | 0 | 5 | 1 | 1 | 0 |
| 3 | Chapinero | 0 | 1 | 0 | 3 | 0 |
| 4 | Meissen | 1 | 1 | 0 | 1 | 2 |
| 5 | West Kennedy | 1 | 0 | 0 | 0 | 1 |
| 6 | Rafael Uribe | 1 | 0 | 2 | 1 | 3 |
| 7 | St. Blas | 2 | 2 | 2 | 0 | 3 |
| 8 | St. Clara | 1 | 1 | 2 | 0 | 2 |
| 9 | Vista Hermosa | 0 | 3 | 3 | 1 | 2 |
| 10 | Centro Oriente | 1 | 1 | 1 | 0 | 1 |
| 11 | Tunal | 3 | 0 | 4 | 0 | 2 |
| 12 | St. Cristóbal | 0 | 0 | 3 | 0 | 6 |
| 13 | Bosa | 1 | 1 | 3 | 0 | 1 |
| 14 | The Victoria | 4 | 1 | 2 | 0 | 7 |
| 15 | Carlos Lleras | 3 | 7 | 4 | 0 | 4 |
| PERCENTAJE | 17.39% | 20,87% | 25,22% | 6,09% | 30.43% | |
* Specialist Doctor ** Chief Nurse *** Genera l Doctor **** Professional with specialization in epidemiology ***** Others
Source: Instrument of the investigation.
2.4. Results per variables
2.4.1 Organizational Factors
The study area Organizational Factors is subdivided in two essential dimensions: the relevancy of the dimension as analysis variable in the context of the organisational learning.
In every dimension it was realized a test of average equality in order to prove if the organisational learning differs among the tangible and intangible factors, which were evaluated by items 6 and 4 respectively.
Analysis of Correlation
Pearson's test of correlation gives us a significant contribution between the dimensions average scores and the total average score, result that allows us to validate the items construction and their pertinence with the organizational Learning.
Analysis of Variance
The variance analysis between the dimensions and the hospitals shows us homogeneity answer tendency.
♦ Tangible Factors:
The mean of the tangible dimension keeps a relative homogeneity with the total average mean, nevertheless it is observed a wide negative deviation in Bosa hospital (13), which presents a mean of 2,77, unlike Carlos Lleras hospital (15), which presents a mean of 3.86.
♦ Intangible Factors:
The mean oscillates between 3,5 and 4,0, rank that expresses tendency homogeneity; nevertheless, the Bosa hospital (15), presents a significant deviation again, towards the negative, with a mean of 2,99, equal to its total average median. Kennedy hospital (5), unlike its tendency in the other dimensions, presents a positive deviation faced to the other hospitals and its total average mean, with a median of 4.0.
Comparisons of Dunnett
Continuing with the difference of hospitals faced to the pattern hospital (Carlos Lleras Camargo), in relation to the organizational factors that most affect the creation and impulse of the organizational learning in the committees of hospital infections, we found that:
The hospital with greater difference faced to the pattern hospital is Bosa hospital (13), with a significance of 0,000. This value is very similar to its significance in each dimension: tangible 0,003 and Intangible 0.008. The hospitals that bear greater relation to the pattern one are Meissen hospital (4) and Tunal hospital (11), with a significance of 1.0.
Tendency or direction of the answers of ítems corresponding to the study area of the organizational learning.
Organizational Factors: In the tangible dimension the 28,9% of the people who answered the survey consider that the hierarchic levels influence in the decisión making of the committee. In the same way, with a very positive tendency (37.4%), the persons declare that the structure of the committee assigns clear responsibilities and determines labor behavior parameters.
When affirming about the information systems and their utility, the 38,3% of the answers determine that these usually are offered in useful language and with access and fast interchange of information. Affirmation that is contrasted with the question that refers to the efficiency of the exchange of information which concentrates the frequency average of the 36,5 %.
It is considered that the institution structure is disadvantageous to the organizational. learning inside the committee of intrahospitable infections with a percentage of 58.1%. This datum differs with a 40% of the interviewed people, who affirm that the strategies of the intrahospitable infections committee are pointed to the organizational learning.
In relation to the answering frequency faced to the intangible dimension it is possible to observe that:
The committee members consider in a frequency of the 42,9% that the strategy that most frequently is used for the decision making in the committee is the convincing-participant one; With a weakly positive tendency the interviewed people think that there is sense of mutual quarrel within the committee, nevertheless in average the 31,6% think that never or that only some times it is possible.
With a noticeable positive tendency (44.3%), the interviewed people think that the expression of emotions and ideas is allowed within the committee of intrahospitable infections, Also the 45,2% of the interviewed people have always felt motivated to experience and to discover new knowledge within the committee
2.4.2 Approaches of management of the knowledge
Two dimensions represent the study area of the organizational learning: the technical-structural one and the behavior one, represented in the survey by items 6 and 4 respectively.
Analysis of Correlation:
The technical structural dimension of 0,741 and the behavior dimension of 0,714 give the contribution of the average score,, with a significance of 0,000 each one. With this correspondence we can demonstrate the pertinence of the dimensions as analysis variable in the context of the organizational learning.
Technical Structural
In the variance analysis - ANOVA- among hospitals it is reflected for the technical structural dimension a relative tendency towards the positive that the mean of the total average, the hospitals (13) and (1) also present a mean of 3,05 being lowest among all the hospitals. The hospital that stands out in the mean 4,11 is number (2), followed by the hospital (11) with a mean of 4.01.
Behavior
The variance among hospitals is in a rank that assigns homogeneity with relation to the development of the behavior management within the committee of intrahospitable infections. The hospital (13), with a mean of 3,04, stands out towards the negative tendency, followed by the hospital (3) with a mean of 3.25. The Hospitals (15) and (4) with a mean of 3,95 are those of greater positive tendency.
Dunnet's Comparisons:
Dunnet's T in Approach of management shows to us an ample difference, like the other variables, between the hospital (13) and the pattern hospital, difference that according to the observed thing in the variance analyses is a difference that is marked by the negative tendency of the hospital (13). The median difference between the hospitals (8) and (5) is emphasized which presents a significance of 0.314. On the contrary the hospitals with significance equal to 1,000 are the (4) and (11) ones.
Tendency or answers direction of the ítems corresponding to Approaches of management of the knowledge
In relation to the items pointed to determine the approach of predominant management in the committees of intrahospitable infections, we can say:
The answer tendency in the technical structural dimension is very positive; in this way, the 35,7% of the interviewed people tend to think that the flow of information with other ESEs or IPS is constant. With homogeneity 30% of the interviewed people always count with technologies like the Intranet.
When they refer to the existence of systems of quality management, 62,8% of the people affirm to have one. In a very clear and defined way, the interviewed people know that when it is required to solve a problem, the most pertinent information is the one that surroundings offer to us. In the same way, with a very positive answering frequency, around 60% of the members of the committee of intrahospitable infections have good practices guides in their institutions.
Finally, when the interviewed people are asked if the clinic practice guides facilitate the development of good practices, the 60% of them say: “always”.
In relation to the answer tendency faced to the items which make reference to the importance that is given to the behavior management, it shows that a great part of the interviewed people (42.6%) think that within the committee of intrahospitable infections corporate values of the institution are recognized and adapted.
With an answering frequency of the 45,2%, the interviewed people say that usually the knowledge level stays when a member of the committee leaves it; in the same way, with a very positive tendency the members of committee of intrahospitable infections consider inopportune to take reasonable and calculated risks.
Finally, with a trimodal frequency allocation, the interviewed people do not demarcate a tendency towards the permissibility that occurs in the committee in relation to novel practices.
3. Discussions and conclusions management approach
In which it was tried to identify the type of management approach of the organizational knowledge that prevails in the committees of Monitoring of Intrahospitable Infections and their consequence in the creation and impulse of the organizational learning. A tendency to the technical- structural management stands out due to the advances that have occurred in the last 11 years, in the promotion of the quality culture and to the management by processes within the Colombian health system, nevertheless, the intraenterprising initiative is being forgotten, there is no security in the team knowledge that is possessed and in the possibility of facing reasonable and calculated risks.
Nevertheless, a very low importance is given to the information of the surroundings. To do it, generates two types of knowledge, like: "learned injuries" that gather the difficulties in the application of a certain subject, and the other in the "better practices" with those successful aspects, contributions that increase dynamics to give answer adapted to the context with fewer errors in the procedures. Pelluffo and Catalan (2002).
It is also evident by the tendency of the answer in items related to the technical - structural dimensions, that the ESEs are weak in the processing, collecting and analysis of the information, when not counting on efficient systems of collecting and sharing of information, leaving it in the rear compared to those institutions that have them.
With a positive tendency, but not so significant as the technical - structural one, the ESEs reflect a tendency to the passive management, developed by those organizations that show low interest on the knowledge management; their management elements are oriented to the development of the economic activities, but they are not used with the purpose of managing knowledge. Prieto and Rivella (2004). This way, although it is counted with processes of quality management, they are only used as strategies for fulfilling and controlling and not as learning tools.
This model in the organization could have been acceptable, if it had remained at the time of stability, with traditional organizations and ample constancy. But the new worldwide and state tendencies are directing to the health sector to changing and unstable surroundings in which the model of passive management is insufficient to generate learning.
There is a low recognition of the corporate values, reflection of the low pertinence that the employees have of their organization. The ESEs have forgotten that the intellectual capital that they have is hardly separable of the people, teams or organizations that generate it and that it only can be shared and understood through personal communications, that are directed to determine the proportions of the organization, its mission, corporate vision and values.
Organizational factors
The homogeneity in the tendency of the answer allows us to think that the tangible and intangible organizational factors that the ESEs present are similar, according to their nature, their aims and their standards. The contrasted negative tendency of the tangible factors shows the absence of structural, technological and strategy tools for the promotion of the learning in the organizations.
It is settled within the structure of the committee of Hospital infections, clear tasks, but influenced by the hierarchic power, preventing that the individual projects its behavior in the institution to which he belongs. Mendez (2003). In the technological and information aspects the lack in more than the half of the institutions, of information platforms as the Intranet and the Internet, leaves the institution in the rear compared to the hospitals that count on these technological supports to respond to the changes of the surroundings, although the health sector moves in predictable scenarios; the new challenge of the competitive companies is to develop economies based on the information technology. Quintero (2003).
The organizational culture as a tangible area in the organizational learning must not be forgotten; an important factor like this, is due to characterize, by happy members, with faith in the future, in an organization with internal and rational consistency within a minimum balance, acceptable compared to its contraries; processes that within the ESEs are difficult to conceive due, among many other reasons, to their management dynamics, which generates cultural and climatic collapses every 4 years, making instability constant.
With a very different tendency from what was found in the tangible ones, the intangible aspects have a positive answering frequency, but the already recognized organizational climate of the hospitals described by Quintero (2003), allows us to think that incapacity to share ideas and to depend on the other is explained by the overdimension of the I in the professionals of the health, even more when there are super specialties.
