- 學位論文
以個案分析與SPC方法研究大學醫院於參與國際醫院評鑑過程中形成的組織行為與流程之改善
A Research of Organizational Behavior and Procedure Improving in a University Hospital Obtaining JCIA by Case Study and Statistical Process Control
摘要
21世紀的醫療體系正面臨劇烈轉型，醫師不再是孤獨的英雄，取而代之的是以病人安全為導向的醫療服務團隊。病人追求醫療的目標除了基本的醫院設備完善到醫師醫術高超，更希望得到醫院感動的服務、精簡的流程、所有醫療服務提供者團隊間的合作及醫療人員的同理心對待。台大醫院具有光榮的歷史，傑出的表現，在備受肯定的同時，民眾亦以超高標準來檢視台大醫院的醫學專業及服務品質。現代的醫療服務中強調的安全品質內容，是需要整個醫療組織的團隊全面整體無縫式的合作才能有效運作，而台大醫院悠久的歷史加上公務機關的屬性，組織行為與文化偏向於傳統上醫療專科各自追求卓越之研究與尖端之醫療技術，較缺乏以病人安全為中心的團隊合作文化。因此，台大醫院主事者選擇利用外部的監測力量國際醫院評鑑（JCIA）來審視醫院內部問題，以準備參加JCIA之過程為啟動組織變革之手段，將組織行為與文化轉型成以病人安全維護為導向，發揮各醫療專業間之團隊合作，減少醫療失誤與浪費之組織行為與文化，以因應這個時代病人的需求，進而提升組織效益。 本研究以個案研究方法，多方蒐集台大醫院在準備JCIA一年的期間，辦理的各種活動之執行歷程及改善結果，並以SPC統計製程管制法(SPC)分析JCIA這個品質提升活動介入前、中、後期對於5項TQIP指標及三日內病歷完成率指標的影響。台大醫院自2009年4月至2010年3月準備JCIA期間推展的一系列作為，蒐集之資料顯示，台大醫院為準備JCIA辦理之各項活動內容包含有：行動初期多方收集JCIA的相關資訊透過各式會議或資訊系統傳達至院內各個領域及階層。為確立行政程序,修訂及新訂各項規章辦法(policy)與作業流程(procedure)（P&P）。經過充分溝通後制訂以病人安全為導向的醫療作業流程。每週定時召開核心工作小組會議以掌控各階段整體進度。由各領域之專責科部負責辦理全院一致性多元及多面向的教育訓練。藉由標竿學習及經驗交流達成病房主任與病房護理長共同負擔病安責任。以追蹤訪查建立改善機制等。所有作為是由上而下，包含所有醫療從業人員將舊有作業習慣及思考模式，從以自己方便為出發點的作業流程改變成以病人安全為前提考量的作業流程，發展出硬體設備更新、無縫式就醫流程及各式醫療作業規範之典章制度各方面都有明顯的改變，如此的改變並非少數人即可完成，而是組織內所有成員群策群力的結果。另從5項TQIP指標及三日內病歷完成率做JCIA前後共三年SPC分析：「有紀錄的跌倒」顯示紀錄發生比率增加，品質管理活動的介入促使台大醫院落實跌倒事件之通報。「跌倒造成傷害」的比率研究期間沒有明顯變化趨勢。「完成治療之前即離開急診室之掛號病人」比率降低，顯示對於病人未完成治療即離開急診的狀況有明顯的改善。「排程當日取消的門診消化系統診斷內視鏡處置比率」於活動介入執行期降低，惟自2010年7月起，指標數值上升，顯示品質提升活動對於該項指標的影響並非長時間持續，經過一定時間後，仍須再次介入。「排程當日取消的其他門診處置」呈現穩定狀態，顯示有顯著且持續影響。「三日內完成病歷率」呈現明顯上升趨勢，且至2011年4月，該指標之比率仍然持續上升。 本研究結論：台大醫院為因應外在環境的衝擊，以參與國際醫院評鑑(JCIA)改變內部組織行為與文化，對組織產生極大的衝擊明顯改變。而從結果亦發現參加JCIA品管認證活動執行的前後幾個月，品質指標有較好的表現，於活動結束後半年至一年間，品質指標表現略為退步，顯示以品管認證活動的手段來改善醫療品質需要持續投入及改善，才能維持品質提升效果。
並列摘要
The medical service system in the 21st century is facing serious transformation. The medical doctors are not the only heroes anymore. The patient safety oriented medical service teams take the place instead. The needs of patients should be fulfilled not only by well established hospital infrastructure and skillful medical doctors, but also by impressive service and compassionate treatment provided by the team work of medical staff. The quality of patient care in modern medical service emphasizes patient safety, which requires seamless cooperation of all well organized medical teams. National Taiwan University Hospital (NTUH) has a long glorious history with prestige in medical specialty performance. In the past, the organization culture of NTUH leaned to aiming at pursuing brilliant researches and cutting edge medical technology, and it put the sense of patient safety care aside. For this reason, the superintendent of NTUH decided to review the internal challenges by introducing external monitoring force, the JCIA, to initiate the organizational behavior and cultural changes via the process of hospital accreditation. Goals they achieved included transformation of the organizational behavior and culture to patient safety centered medical care and improvement of the medical care efficiency. This research is a case study of NTUH’s changes in organizational behavior and culture before and after JCIA through reviewing the processes and records of all activities conducted in the one-year preparation period for JCIA. Five TQIP index and the completion rate of medical record within three days after patient discharge were also analyzed by using Statistical Process Control (SPC) method. During the preparation period for JCIA, from April 2009 to March 2010, NTUH conducted many activities including delivering JCIA related information to staff at all levels through all channels, establishing and refining administration policies and procedures, establishing patient safety oriented medical operation procedures, holding core team conference every week to monitor the process in every phase, training staff in every department with appropriate and consistent content, assigning the director and the head nurse in every ward to take responsibility of patient safety, sending auditors to every department to confirm all JCIA patient safety standards are in place, and establishing a mechanism for continuous improvement. Findings from SPC analysis of five TQIP index and the completion rate of medical record within three days after patient discharge were first, NTUH staff became more willing to report patient safety events than before. Second, the ratio of cancellation of the scheduled examination and emergent service decreased significantly. Third, the completion rate of medical record within three days after patient discharge increased remarkably. The results of the case study showed NTUH, a public and large scale university hospital with over a hundred years history substantially changed organizational culture and procedures by obtaining JCIA.
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