探討醫院評鑑檢驗組之品質指標及對醫療品質之影響

A Study of Laboratory Quality Indicators of Hospital Accreditation and It's Impact on Medical Quality

黃于珊(Yu-Shan Huang)

指導教授 ： 邱亨嘉 ； 陳百薰

高雄醫學大學/健康科學院/公共衛生學研究所/碩士(2003年)

摘要

背景與目的：
過去鮮少研究者專門針對檢驗組評鑑進行相關分析，且在資料庫分析方法多為較少利用縱貫性研究設計(Longitudinal study design)。因此本研究欲透過問卷調查與歷年評鑑資料庫來探討檢驗組評鑑之相關議題，主要研究目的可歸納為以下四項：1）探討八十九年度醫院評鑑檢驗品質指標之效度及信度；2）統整地區教學以上醫院之檢驗科主管對醫院評鑑制度之意見；3）歸納「重要且較可信」之檢驗品質指標；4）探討不同年度間各層級醫院檢驗科之醫療品質改善情形。
方法與材料：
本研究從八十九年度醫院評鑑資料表與評量表挑出研究指標，之後再分別進行問卷調查與歷年度（83、86與89年度）醫院評鑑資料庫分析，其中問卷設計採李氏五等量表之設計來評估指標之重要性與可信度。
問卷調查部分，採郵寄之方式寄送並輔以電話催收與問卷補發；研究對象為6位「曾任或現任之檢驗組評鑑委員」（回收率100％）與125位「地區教學以上醫院之檢驗科主管」（回收89份，總回收率為71.2%），但醫學中心回收率不到七成。在資料庫部分，資料來自於衛生署歷年醫院評鑑資料光碟及相關書面資料。
分析結果：
評鑑委員與主管在重要性與可信度評量之比較中發現，在24項結構面指標之重要性與可信度評量上則均未呈現顯著差異；在44項過程面指標之重要性評分有3項達顯著差異，而可信度評量上則有5項，且主管之平均得分顯著高於評鑑委員之平均得分；在13項結果面指標之重要性評分僅有1項達顯著差異，但在可信度評量上則有5項有顯著差異。
在主管開放性問題中，有78.4％之主管認為評鑑項目不足以代表檢驗品質；而針對本研究重要但可信度較低之指標改進方法，大致上分成制度改進與內部加強控管兩個方面。至於對於現行檢驗組評鑑制度之其他意見則有修訂評鑑標準、評鑑委員遴選之考量、改採CNLA認證等。
從資料庫分析中發現，在區域以上醫院部分結構面與結果面在歷年度評量中多有所進步，但歷年過程面指標則多呈現不規則起伏（如：先升後降或先降後升），而地區教學醫院則在三個構面均有顯著改善。而整體而言，醫院評鑑制度實施後之檢驗品質呈現改善之趨勢，且89年度普遍較86年度或83年度為佳。
討論與建議：
本研究問卷在結構面指標之重要性與可信度評量上，不論是評鑑委員與主管間或是不同層級主管間之比較均顯示比較族群在指標認同上沒有顯著差異；在過程面指標與結果面指標上，所有比較族群在重要性與可信度評量上之看法大致相同，但在可信度部分卻與假設不符。可能原因為測量不易或委員評分標準不同。
從資料庫分析中發現過程面指標在歷年表現上多存在驟升驟降之現象，這樣的結果可能原因有二，一為評鑑委員評分之差異或每年度評量重點不同所致，而另外一個原因可能在於過程面指標相對於結構面或結果面指標來得不易定義與測量，造成人為誤差也相對較大，因此有關單位應將過程面指標明確定義以減少偏差。
從以上之結果可以發現，目前現行之評鑑項目多屬重要指標，而指標之可信度雖然多無差異，但明顯可見評鑑委員或主管對於可信度之評分比重要性之評分來得低，尤其在過程面指標部分；另外從資料庫分析中發現，歷年來檢驗品質有一定程度的改善，但進一步從主管之意見來看，要達到更合理的品質評估尚須有關單位繼續的關切與努力。

關鍵字

醫院評鑑 ； 檢驗 ； 醫療品質 ； 品質指標 ； 實驗 ； 實驗室流程時間 ； 精確度調查

並列摘要

Background and Objectives：
In Taiwan, there have been only few studies concerning hospital accreditation in department of laboratory medicine by using longitudinal study. We investigated the effects of accreditation on laboratory medicine through questionnaires and database of hospital accreditation. The main objectives of this study were: (1) to study the validity and reliability of quality indicators of hospital accreditation in department of laboratory medicine for the year of 2000 in Taiwan; (2) to investigate the opinions about hospital accreditation from those chiefs of laboratory equal to and greater than district teaching hospital; (3) to find quality indicators in laboratory which were important and reliable; (4) to investigate the improvement of medical quality in department of laboratory medicine since the implementation of laboratory inspection.
Materials and Methods：
From the database and inspection scale of Hospital Inspection in the year of 2000, we investigated the study indicators through questionnaire. We also analysed and compared the data with those inspection data of the year of 1994, 1997. The questionnaires were designed to evaluate the importance and reliability of indicators based on Five-point Likert Scale. The self-designed questionnaires were sent to laboratory directors equal to and greater than district teaching hospital in Taiwan during the period of March to May, 2003 by mail. The response rate was 100 % (6/6) for members of laboratory inspection and 71.2 % (89/125) laboratory directors, respectively.
Results and Conclusion：
There was no significant difference of importance and reliability between members of inspection and laboratory directors for 24 indicators in structure. The mean score in importance and reliability was significantly higher in laboratory director than in members of inspection. Among 13 indicators in outcome, there was only one item in importance and 5 items for reliability revealed significant difference. In open questions, 78.4％ of directors thought that inspection items were not good enough to represent laboratory indicators. They were two main suggestions for improving those indicators that were important and less reliable in this study: system improvement and internal quality control. Through data analysis, for those area hospitals, there was much improvement in the field of structure and outcome indicators, but there was fluctuation for process indicators. For those district teaching hospitals, there was significant improvement for all indictors. Overall, laboratory quality improved since the implementation of hospital inspection, and the total performance in the year 2000 was better than that in the year 1997 and 1994. For indicator in structure, there was no significant difference for importance and reliability between laboratory directors. For indicators in process and outcome, it is almost the same for importance and reliability. Our studies indicate that most inspection items were important. However, the reliability scores of indicators were less than the importance scores, especially in process indicator. Laboratory directors of hospital believed that there still need great effort for improvement through hospital inspection.

並列關鍵字

Hospital Accreditation ； Hospital Inspection ； Medical Quality ； Quality Indicators ； Laboratory ； Turnaround Time ； Proficiency Test

參考文獻

中文參考文獻：

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王美芳（1994）。我國地區醫院功能之研究。中國醫藥學院醫務管理學研究所碩士論文。

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