台灣醫院評鑑制度運作之研究

A Study on the Operation of Hospital Accreditation System in Taiwan

林淑綿(Su-Mien Lin)

指導教授 ： 張四明

國立臺北大學/公共事務學院/公共行政暨政策學系/碩士(2010年)

摘要

台灣醫院評鑑制度實施三十餘年，其中不乏評鑑結果與醫療品質相關研究，惟對評鑑制度運作研究較少。透過醫院評鑑基準，再加上兩項重要法規約束－醫療法與全民健康保險醫事服務機構特約及管理辦法，全台灣四百多家醫院莫不被醫院評鑑制度牽動、影響著。若說「醫院評鑑」與「健保給付」制度，同為國家機關（行政院衛生署）對其治理對象（醫療機構）所使用最有效之政策工具；那麼相較之下，「醫院評鑑」制度發展沿革及政策形成之過程，似乎比全民健保改革相對平順許多。但這促使醫療機構自發性、自律性提升自我品質的制度，是否符合眾意且發揮應有效能，是本研究欲瞭解目的之一。自1999年起，有鑑於國際上各先進國家「醫院評鑑」工作多由民間專門機構統籌辦理，行政院衛生署遂與民間相關醫事團體共同捐助設立「財團法人醫院評鑑暨醫療品質策進會（簡稱醫策會）」，協助政府執行「醫院評鑑」及「醫療品質提升」業務，如何透過此「非營利組織」繼續強化我國醫療體系，協助醫院持續性醫療品質改善，又是否符合國人所需，此為本研究另一項研究目的。
　　本研究針對與評鑑制度習習相關的五大核心問題：評鑑基準設計妥適性、評鑑委員聘任方式與任期合適性、評鑑結果運用合適性、評鑑功能發揮充分性、及對「醫策會」角色任務之評價，透過政策評估六大標準（效果、效率、充分、公平、回應、適切）及利害關係人論點（官方、產業及學方等20名學者專家），利用文獻分析法瞭解我國醫院評鑑沿革、國外先進國家之發展，及近期較具爭議性議題擬定問題面向，再採用德菲法邀請這20位學者專家進行二回合循環問卷，最後針對未達共識項目進行專家意見調查，以瞭解台灣醫院評鑑制度運作之現況。
　　研究結果發現：
1.台灣評鑑制度改革多師法國外先進國家，且改革速度已與其並駕齊趨；
2.雖德菲問卷結果「與健保給付支付標準結合機制」未達多數認同，但從文獻分析及政策發展來看，我國醫院評鑑制度發展特色與保險給付習習相關，「醫院評鑑」、「醫療品質」及「保險給付」如能有效結合，應是共生、共存及共同進步的鐵三角關係；
3.評鑑基準設計中以「必要項目非過不可」機制最被認同，「包羅萬象之評鑑基準」最不認同；
4.評鑑委員制度認同度最高為「評鑑委員應有退場機制」，認同度較低為「一年一聘機制」；
5.評鑑結果運用意見尚有分歧，仍需多方協商討論；
6.評鑑功能在「有助於醫院發展自我特色」之發揮需再加強；
7.醫策會評鑑作業具有公信力及專業性普遍獲得認同，但能否成為溝通平台仍有改善空間。
針對以上研究結果研究者提出幾項政策建議：政策決策者對於評鑑基準應有把關及嚴選之功能與機制；應適時檢討評鑑委員遴聘、評核制度，並延長委員聘期或建立專任委員制度；評鑑結果公開時勢所趨，惟公開內容及方式仍需各界進行協商；加強發展且具有自我特色醫療機構之評鑑功能；醫策會可在成為醫界與政府溝通平台之角色多予著力；對於未來評鑑制度發展應借助他國經驗，使民眾得到更適切、更以病人為中心之醫療環境。

關鍵字

醫院評鑑 ； 政策評估 ； 利害關係人 ； 德菲法

並列摘要

The Hospital Accreditation System (HAS) has been implemented in Taiwan for more than over 30 years. Several researches concerning the results of accreditation and healthcare quality; however, seldom has focused on the HAS operation. In Taiwan, over 400 hospitals to be regulated by the hospital accreditation standard because of two significant Acts: the Medical Act and the National Health Insurance (NHI) Act. If both HAS and NHI payment system are the most effective political implements the authority (the Department of Health, the DOH) has enforced on the healthcare institutions, the formation and development of Hospital Accreditation is easier (smoother) than the revolution of the NHI. So, the objective of this study aims to find out if HAS, a system which is supposed to encourage healthcare institutions to be more spontaneously and self-disciplinarily enhancing their quality, meets the expectations of the public and if the system is operated effectively as it should be. In 1999, the Taiwan Joint Commission on Hospital Accreditation (TJCHA), a not-for-profit, non-governmental organization, was established and funded by the DOH, and a lot of the medical associations. TJCHA was founded to help the government execution hospital accreditation and improving healthcare quality. The other purpose of this study is to find out how effective the TJCHA organization is performing the hospital accreditation.
　 The study focus on five core themes closely related with the HAS, the appropriateness of Accreditation Standard design, the appointment and the terms of service for surveyors, the utilization of accreditation results, the function of hospital accreditation and people’s conception toward the role and mission of TJCHA. The study evaluates the policy with the six Policy Evaluation Criteria (effectiveness, efficiency, adequacy, equity, responsiveness and appropriateness) and Policy Stakeholders (government, industry and scholar) opinions to discuss controversial subject. First, the researcher utilizes literature review to understand the development course of hospital accreditation in Taiwan, in other countries and also the most recent controversial issue. Then, Delphi Method is utilized to conduct a two-round-survey with 20 specialists. Afterwards, the researcher collects free-back from the specialists on those subjects which do not reach mutual recognition.
　　The results of the study are,
1.Taiwan's HAS reform has learned a lot from different countries, and has kept its pace with them.
2.Although results of questionnaires did not agree the connection between the hospital accreditation and health insurance reimbursement, it would gain better result if hospital accreditation, healthcare quality, and health insurance reimbursement could work effectively.
3.In the appropriateness of Accreditation Standard design, the most approved is the mechanism of the passing of Required Items; and the least approved is the comprehensiveness of standards.
4.In the appropriateness of Surveyor System development, the most approved is the dismiss mechanism of surveyors; and the least approved is hospital surveyors' one-year term of service.
5.The utilization of accreditation result does not reach any consensus; therefore, it still needs opinions and discussion from different professional healthcare-related bodies.
6.The accreditation function must strengthen on the aspect to help hospitals to develop itself characteristics.
7.TJCHA should strengthen its role to communicate between the authority and healthcare industry.
According to the findings, several suggestions are: 1.policymakers should be the gatekeepers of the accreditation standards, 2. to evaluate the surveyor system, especially appointment and evaluation, 3. to discuss the public disclosure of the accreditation results, 4. to strengthen in helping the hospitals to develop itself characteristic, 5.to strength the role of TJCHA to become the communication platform between the government and the hospitals, and 6. to learn from other countries' experience to establish a safe, efficient, patient-centered healthcare environment.

並列關鍵字

hospital accreditation ； policy evaluation ； policy stakeholders ； Delphi method

參考文獻

尹裕君（2005），＜新制醫院評鑑與護理品質管理＞，《榮總護理》，22（2），頁109-116。

王中民（2008），《提升新制醫院評鑑準備效率之研究》，長榮大學高階管理碩士在職專班碩士論文。

王俊文、葉德豐、曾坤儀（2003），＜台灣醫院評鑑趨勢之探討＞，《中山醫學雜誌》，14（4），頁513-522。

石曜堂等（2008），＜醫療品質發展趨勢探討＞，《台灣醫界》，12（6），685-690。

宋文娟、藍忠孚、陳琇玲、詹錕鋙（1999），＜臺灣醫師人力政策當前重要課題之專家意見分析＞，《中華衛誌》，18（5），頁334-340。