從醫院治理觀點論醫護過勞議題的法政策回應

A legal and policy analysis of the issue of overwork in healthcare from the perspective of hospital governance

傅國峻(Kuo-Chun Fu)

指導教授 ： 梁志鳴

臺北醫學大學/人文暨社會科學院/醫療暨生物科技法律研究所/碩士(2018年)

摘要

我國醫師及護理師面臨嚴重的過勞問題，工作時間過長的情形相當普遍。面臨這樣的問題，我國政府試圖透過將護理師納入勞動基準法的保護，或是透過相關的法規命令來規範醫師的工作時數，而在執行面上則透過醫療評鑑來加強落實關於人力配置的規範，同時也由勞動主管機關來稽查醫院是否違反勞動法規。然而，這些政策飽受外界批評，稱其無法有效改善過勞的現況，另一方面在關於醫護員工過勞的訴訟案件上，法院判決實務上常未質疑醫療勞動環境的合理性，因而難以期待透過司法途徑建構對於醫護有利的勞動權利保障。

本文觀察到這些立法政策與法院判決實務上，都是屬於偏重外部監控的觀點，而較少討論醫院內部經營對於醫護勞動環境的影響。有鑑於此，本文之研究乃以醫院治理理論為研究途徑，嘗試觀察醫院治理與醫護過勞問題兩者之間的關聯性。而透過文獻回顧之研究方法，本文發現到醫院治理其實與公司治理有高度之關聯性，兩種均以解決代理問題為核心，本文於是以公司治理之相關理論作為參考框架，發展出醫院治理的三方面分析架構，分別是治理結構、決策機制、與資訊揭露，本文亦以此架構作為研究及論述上的主軸。

基於醫療機構在我國具有肩負我國國民健康的重要地位，且因全民健康保險的醫療體系下使無論是營利醫院與非營利醫院都帶有相當之公益性或社會財屬性，因此醫院的經營良莠實際上影響廣泛的利害關係人，這些利害關係人包括病患、醫院員工、供應商、社區、社會、環境等。因此若從醫院治理來思考醫護過勞議題，本文認為必須更重視醫院經營與這些利害關係人的關係，尤其是這些利害關係人彼此間具有相互影響的作用，特別是當醫院長期忽視醫院員工的勞動條件時，其實會對於院內的醫療品質及病人安全產生負面影響。而這個情形其實已實際反映在我國醫院治理實務上以及現行法制上，常見有論者批評醫療財團法人自我圖利卻未照顧到院內員工。而關於利害關係人的保護，主要是醫院社會責任的探討範疇，本文也透過文獻回顧之研究，發現許多醫院對其自身的社會責任看法雖然是肯定的，但是卻普遍未意識到院內醫護員工也是利害關係人的群體之一。

有鑑於此，本文提出一些具體的改善方案，而雖然近期衛福部提出之醫療法修正草案已試圖透過改善醫院治理來回應醫護過勞問題，具體法律修正包括董事會增設員工代表以及醫院盈餘優先補充人力，然而本文認為相關修法對醫療機構利害關係人之重視仍有所不足。本文於是從強調利害關係人角色的角度出發，具體提出包括透過員工董事制度、社會責任報告書、勞動權益委員會等制度改革提案。此外，本文透過訪談研究發現，醫院企業工會可能也對於醫院治理有正面影響。總而言之，本文研究結論認為在醫護過勞議題上，醫院治理的觀點應可以補強外部治理的不足，值得未來政策制定或後續研究之參考，期能改善醫護勞動環境。

關鍵字

醫院治理 ； 治理結構 ； 資訊揭露 ； 決策機制 ； 利害關係人 ； 醫院社會責任 ； 醫院企業工會 ； 醫護過勞

並列摘要

The overwork problem in healthcare is a big issue in Taiwan, the working hour is generally too long for physicians and nurses. To face this issue, our government tried to place nurses under the protection of Labor Standards Act, and tried to limit the working hours of physicians by regulations. In the aspect of implementation, the government used Hospital Accreditation System to enforce the regulations about the staffing requirements in hospitals, and also used Labor Inspector to examine the violation of labor regulations in hospitals. However, these policies faced with criticism, people criticized that those policies fall to improve the problem of overwork. On the other hand, there has been many legal issues related with overwork problem in healthcare, however these judgements reveal that the Court often have no query about the rationality of the working environment in hospitals, and therefore the judicial approach was hardly to be expected to secure the labor right of physicians and nurses.

This thesis observed that those government policies and court judgment practice described above are from a perspective of external monitoring, which reveals that people rarely discuss that what could internal management in hospitals have influences on the overwork problem in healthcare. In the light of this situation, this thesis use hospital governance theories as a research approach, and try to find out the relation between hospital governance theories and the overwork problem in healthcare. Through the method of literature review, this thesis found out that hospital governance is related to corporate governance, both are on the basis of agency problem. Consequently, this thesis take the research literature of corporate governance as a frame of reference, and proposed an analysis of the structure which contains the governance structure、the information disclosure、the decision making mechanisms, and these are also the research focus of this thesis.

Since medical institutions in Taiwan borne the weight of taking care of the health of the people, and also on account of healthcare system in National Health Insurance which made profit hospitals and non-profit hospitals possess of public welfare or social goods. Therefore, the management of hospitals is actually having a lot influence on a wide range of stakeholders, and this stakeholders include patients, employees in hospitals, providers, community, society, environment and so on. Consequently, if we think over the overwork problem in healthcare through the view of hospital governance, the perspective of this thesis is that we should put more emphasis on the relations between hospital governance and the stakeholders. Especially, a group of shareholders could have influence on other group of stakeholders, which means that when hospitals ignore the working conditions of physicians and nurses in long-term, this situation could result in negative impact on the quality of care and the patient safety. In fact, this situation has reflect on the practice and the regulations of hospital governance in Taiwan, there are criticism about the self-profit of the hospital establish by medical foundations, these hospital take little care of their employees. With regard to stakeholders, which is the subject of hospital social responsibility, this thesis found out that many hospitals hold a positive attitude on hospital social responsibility, however most of them did not realize that physicians and nurses in hospitals are also a large group of stakeholders.

Given that the situation described above, this thesis proposed a few concrete resolutions. In particular, there is one thing worth mentioning, the draft amendment for Medical Care Act recently proposed by Ministry of Health and Welfare showed the intention to respond the overwork problem in healthcare by improving hospital governance, which included the article that stipulate the employee representatives in the board of directors and the surplus of the hospital should be used in supplement to manpower as a top priority. However, in the point of this thesis, this amendment is not adequate enough for the overwork problem in healthcare, hence this thesis consider that more emphasis should be put on stakeholders, the resolutions include worker directors, social responsibility report, labor rights committee and so on. Additionally, this thesis contains an interview study, which discover that the enterprise labor union in hospitals may has a positive influence on hospital governance. In conclusion, the result of this thesis were that hospital governance could be a reinforcement to external monitoring, which could be a reference to the follow-up research or policy making, and hope this thesis could improve the labor environment in healthcare.

並列關鍵字

hospital governance、governance structure、information disclosure、decision making mechanisms、stakeholder、hospital social responsibility、hospital corporate union、overwork in healthcare

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