參加臺灣醫療照護品質指標系列(THIS)之醫院實施現況及意見調查

目標：本研究目的在調查參加臺灣醫療照護品質指標系列(THIS)之醫院執行現況及意見。方法：本研究先採用焦點團體方法發展的結構式問卷，再針對參加THIS的234家醫院進行普查，以電子郵件寄給THIS的負責人或主管，調查其蒐集THIS指標的現況與所遭遇的問題、是否運用指標改善品質、以及對醫院之影響。結果：回收有效問卷共120份（回收率為51.3%），各醫院曾經提報過的指標數，平均有67項，提報比例占所有139項指標的48.2%。最多醫院選取要提報的指標標準為數據容易取得與可改善程度。收集資料的最普遍方式為一半由人工、一半由資訊系統擷取。收集及分析指標可能面臨的最常見問題為指標收集相關業務人力不充足及指標分析能力較弱。在指標結果之應用上，許多受訪者是提交給院方參考及與醫院評鑑業務結合。參加THIS所帶來的效益，最多醫院認為可協助發現品質問題及提升院內醫療品質。結論：本研究建議參加醫院可藉由e化，使數據蒐集變得較容易，不但可增加提報率，也能減輕相關業務人員的工作負擔。除此，醫務管理學會可定期舉辦統計分析課程或THIS應用研討會，增加參加醫院對THIS指標的分析能力或結果之運用，進而採取有效的行動，以提升績效。

關鍵字

醫療品質；臺灣醫療照護品質指標系列；醫院管理

並列摘要

Objective: This study surveyed staff of hospitals participating in the Taiwan Healthcare Indicator Series (THIS) Project regarding their experiences and opinions of the project. Methods: A structured questionnaire was developed via a focus group technique. The questionnaire was then forwarded to employees or directors dealing with THIS of all 234 hospitals participating in the project via electronic mail. Questions included current implementation status, problems encountered, and applications and impacts of the THIS project. Results: 120 effective responses were obtained (representing a response rate of 51.3%). The average number of reported indicators per hospital was 67. THIS included a total of 139 indicators. The most frequently used indicator selection criteria were the ease of data collection and the potential performance improvement. The most popular method of collecting data was semiautomatic. The most commonly encountered problems concerning collecting and analyzing indicators were insufficient manpower for gathering indicators and inadequate indicator analysis ability. In terms of applications of the THIS statistics, many respondents answered that they planned to submit the statistics to their chief executive officers and then integrate in the preparations for hospital accreditation. Most respondents considered participating in THIS to be helpful in identifying quality issues and improving quality of care. Conclusions: This study suggests that participating hospitals should consider collecting data through e-operation to increase reporting rate and reduce employee workload. Furthermore, the Taiwan College of Healthcare Executives can periodically hold statistical analysis workshops dealing with the THIS applications to help participants to improve their ability to analyze data and further improve hospital performance.