自主管理制度對急診醫療品質影響之分析

The Impact of Hospital-Based Global Budget on Emergency Departments

陳維恭(Wei-Kung Chen)

指導教授 ： 龔佩珍

亞洲大學/健康學院/健康管理研究所/碩士(2005年)

摘要

民國93年推動的自主管理(醫院個別總額)，對台灣而言是一個新的健康保險制度，醫院個別總額是以費用控制為目的，對醫院因而造成許多的衝擊。由於急診醫療是醫院第一線的服務部門，本研究的研究目的，即在分析及探討醫院個別總額後急診醫療品質所受的影響。
本研究以結構式問卷調查的方式進行，研究對象為醫學中心、區域醫院及地區教學醫院之急診主管及其醫護人員。問卷內容包括醫療品質的結構面、過程面、結果面及評估指標，急診主管則增加醫院面對自主管理後策略運用的問項。資料以描述性統計外，推論性統計包含卡方分析（χ2 test）、spearman’s 一致性分析，並以羅吉斯迴歸分析醫護人員在各項評估指標之影響因素。
本研究共計回收有效問卷包含醫護人員609份(47家醫院)及急診主管38份(38家醫院)。研究結果顯示不論是在結構面、過程面或結果面，急診醫護同仁認為自主管理後對急診醫療品質產生負面的影響。而從主管醫院策略運用的結果可以看出，這些對急診的影響和醫院採取的策略有關。醫護人員的卡方分析結果，有無加入自主管理、醫院的等級以及醫院屬性在結構面、過程面或結果面等構面上均有顯著差異，但主管的卡方分析結果差異性較小。依據羅吉斯複迴歸分析結果顯示，認為自主管理對急診衝擊很大的，在醫學中心是地區醫院的1.995倍；自主管理後醫院大力於成本控制，有加入自主管理是無加入自主管理者的2.105倍，對急診作業流程影響很大者，私立醫院是公立醫院的2.290倍，年資超過10年之醫護人員為年資小於5年醫護人員的2.639倍；認為急診醫療品質因自主管理制度後有退步者，在有加入自主管理之醫院是無加入自主管理之醫院的2.097倍、醫師是護理人員的2.166倍，年資5至10年或超過10年為年資小於5年者之1.790倍及2.724倍。因自主管理制度後因而考慮離職或更換醫院者，年齡小於30歲者，為年齡40歲以上之3.144倍。
本研究從醫護人員的角度顯示自主管理後，對急診醫療品質產生了許多負面的影響，這些影響來自於醫院經營策略的改變。未來醫院個別總額若要持續推動，必須注意到急診所面臨到的問題，否則急診醫療照護品質以及急診病人的權益，恐怕會有不良的影響。我們的建議是1.對急診主管及醫護人員而言，必須進行更有效的管理及人力調度。此外，在資源有限的情形下，必須建立各項標準作業及臨床照護指引，以加速流程、減少等待，又可以降低醫療的風險。2.對醫院而言，人力的調控必須相對於服務量的成長，而且必須主動監控醫療作業是否有不正常的改變，以避免影響急診疏散病人的機制，主動說明及溝通總額制度的變化以降低衝擊。3.對健保局而言，應採取更有效且直接的品質監測指標，以保險人所要的醫療品質為監測項目，而不單以公衛的指標來衡量品質。4. 對衛政主管單位而言，應主導醫療政策的走向，引進適合台灣的醫療保險制度，並務實地採用適當的費率。

關鍵字

急診、醫院個別總額、照護品質、健康保險

並列摘要

Hospital-based global budgeting (HBGB) is a newly introduced insurance policy in hospitals in Taiwan. The key purpose of HBGB is to control the increasing medical expenditure. However, hospitals who join the scheme lose the incentive to expand their services due to the fiscal restrictions imposed by the HBGB. This has had a considerable impact in most hospitals. As the gatekeeper of the hospital the emergency department is providing medical care at the frontline. It is therefore postulated that the impact of the HBGB was greatest in this department. The purpose of this study was to analyze the extent of the impact of the HBGB on EDs and ED staff in Taiwan.
A structured questionnaire was created and sent to nurses and physicians at EDs. The content of the questionnaire included self-reported assessments based on a rating scale which measured the impact of the HBGB on the ED with regard to structure, process, outcome and overall satisfaction. The questionnaire also included questions about the strategies hospitals had adopted to cope with the restrictions of the HBGB. Descriptive analysis was applied to the rating of HBGB impact. Logistic regression analysis revealed that the independent variables were type of hospital, whether hospital joined HBGB or not, the level of hospital, duration of work in the ED, and job type (nurse or physician).
There were 609 respondents (nurses and physicians) from 47 hospitals and 38 respondents (other hospital staff) from 38 hospitals. The HBGB mainly affected the EDs structure, process and outcome according to the nurses’ and physicians’ questionnaires. Most of the impact of the HBGB was related with the hospitals’ responses to the HBGB. The rating scales were significantly different between HBGB and non-HBGB hospitals, and among different levels and types of hospital. The impact of HBGB was greater in medical centers than in local hospitals (odds ratio=1.995, 95% CI 1.145-3.476). The impact of cost control was greater in HBGB hospitals compared with non-HBGB hospitals (OR=2.105, 95% CI 1.370-3.234). The impact on the process in EDs was 2.290 times greater in private hospitals than in public hospitals (OR=2.290, 95% CI 1.176-4.459) and 2.639 times greater in senior (≧10 years) than in junior (< 5 years) ED workers. Quality of care was 2.097 times lower in HBGB hospitals than in non-HBGB hospitals. In addition, 2.166 times more physicians than nurses considered the quality of care to have decreased. Furthermore, nurses or physicians who had worked at the ED for 5-10 years and 10 years were 1.790 times and 2.724 times than junior ED staff considered the quality of care to have decreased after implementation of HBGB. There were 3.144 times (95% CI 1.305-7.577) more staff aged under thirty years than those over forty who reported a greater willingness to change job or hospital after HBGB.
The HBGB has had a considerable impact on EDs in Taiwan. Most of the impact had arisen from the hospitals’ responses to the HBGB. Health policymakers need to consider providing EDs with supplementary support, and must closely monitor the effects of the HBGB in order to maintain normal functioning of the emergency medical services. For the EDs, we advise that more effectiveness manpower utilization system have to apply to resolve the inadequate ED’s manpowever. Furthermore, using clinical guideline to shorten the waiting time and decrease the rish of legal problems. For the hospital administrators, ED’s manpower has to fit the increasing volume of patients. In addition, setting up a backup surveillience system to the ED is advised. For the BNHI, more effectiveness quality indicators are requirement. For the Department of Health, introducing a appropriate health insurance program is very importance. In addition, DOH have to seriously consider to adjust the NHI premium rate.

並列關鍵字

emergency department, hospital-based global budget, quality of care, health insurance

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