醫師對醫療品質管理之態度-以某醫學中心為例

Physicians’ Attitude on Healthcare Quality management in a Medical Center

楊秋美(Yang Chiu-Mei)

指導教授 ： 郭乃文

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2009年)

摘要

醫師在醫療照護系統中居樞紐性之地位，是醫療服務的守門員，治療決策之建立者，在品質改善中需要扮演重要角色。然而許多醫師似乎不熱衷參與醫療品質改善促進活動，在品質改善計劃中醫師參與似乎存著許多障礙。因此，本研究之主要目的在於了解北部某醫學中心醫師對於醫療品質促進活動與醫療品質管理之態度相關因素探討，期能提供院內管理者推展醫療品質促進活動與管理之參考。
本研究為橫斷式研究，採結構式問卷調查並以醫師為調查對象，問卷包括受試者之基本資料以及醫師對於醫療品質促進活動、各醫療專科品質管理活動、院內全院性品質管理活動之態度與相關因素。本問卷邀請五位專家進行專家內容效度之檢測，同時亦分析研究工具之信度。

主要結果如下：
一、共發出960份問卷給醫師，回收441份(總回收率為46%)，排除15份無效問卷，有效樣本回收率為44.4%。研究發現受試者多為主治醫師(45%)及外科科系(38%)之醫師，且多數在機構中已工作1-3年(24%)及年齡層為21-30歲(45%)。
二、醫師對於該機構推展醫療品質促進活動之了解狀況，主要依序為實證醫學EBM(89.2%)、臨床路徑Clinical pathway（78.2%）、5S（69%）、品管圈QCC（56.4%）、台灣品質指標監控計畫TQIP（48.6%）、內外顧客滿意度調查（40.2%）、ISO（34.3%）、標竿學習Benchmarking（31.4%）、改善提案審查IE提案（25.7%）。
三、醫療品質促進活動專科計畫與活動聯繫窗口產生方式主要以：單位指派佔60.1%居多，但自由參加與個人興趣達10.6%。
四、參與醫療品質促進活動最大的障礙依序為：需要投入許多時間(65%)、缺乏相關資源(35.7%)、缺乏誘因(與晉升較無關)(28.4%)、對於自我專業提昇較無意義(21.6%)、缺乏領導者(17.8%)。
五、針對醫療專科品質管理之態度與院內全院性醫療品質管理活動之態度研究發現，有75%醫師同意或非常同意醫師參與醫療品質改善是很重要的。而81.3%醫師認為醫療專科應該有品質指標監控管理，77.5%醫師認為醫療品質改善需要全員參與，73.5%醫師認為成立跨部門品質管理中心可提供品質促進明確方向，上述這些因素對於增進健康照護品質具明顯之影響。而擔任主治醫師、擔任行政業務、教職、年齡較大且較資深、擔任部科品質促進計畫活動聯繫窗口等醫師均認為這些品管活動有助於改善健康照護品質。
依據研究結果提供以下建議：
一、醫師對於各部科持續醫療品質促進活動中指標監控，建議以台灣品質指標計畫(TQIP)提供醫療專科檢討與改善依據，透過電腦資訊化管理，與實證醫學結合。
二、應積極鼓勵有興趣者共同參與，主動提供相關訊息形成文化，對於推展全面品管將有助益。
三、針對醫師參與品質促進活動最大障礙，透過組織成立跨部門品質管理中心及教育訓練，提供品質促進明確方向，由醫師參與且為中心領導者，進行醫療專科間溝通與協調。
四、品質管理之教育可從各醫療專科例行性品質改善檢討著手，搭配行政管理部門提供給醫療專科之資料回饋應以實證為檢討依據，且與各醫療專科品質促進計畫活動與聯繫窗口共同參與並推廣。
五、醫師擔任部科品質促進計畫活動與聯繫窗口不管在醫療專科品質管理活動或全院性品質管理活動各項檢定皆有顯著差異並佔重要角色，為達到全員參與及推展全面品質管理（TQM），應多宣導推展與教育訓練。
六、醫學生教育應將醫療品質管理概念與臨床應用納入必要醫學教育課程內，才能落實醫療品質活動並與臨床結合。

關鍵字

醫師態度 ； 醫療品質促進活動 ； 醫療品質管理

並列摘要

Physicians are of the most critical module of healthcare systems and supposed to be responsible for healthcare quality improvement. In fact, most of them are rather indifferent and even have negative willingness on quality improvement practice. This study is designed for dissecting the attitude of physicians to quality improvement practice activities, with the specific aim of identifying factors which may be amended.
The survey was cross-sectional study and performed by using a structured questionnaire. The format of questionnaires included basic information of respondents, wanted to understand the related factors of physician’s attitude on healthcare quality improving activities in clinical departments and the institute and healthcare quality management. The items of questionnaires were verified for the content validity index (CVI) by 5 expert panel judges. The reliability analysis was also performed and showed good Cronbach's alpha value, which are 0.871 and 0.878.
The major findings were：
1.Nine hundred and sixty questionnaires were distributed to physicians. Four hundred and forty-one (45.9%) responded the survey. Fifteen incomplete questionnaires were excluded from the analysis. The response rate was 44.4%. Most respondents were attending physicians (40%) and surgeons (36%). Most respondents (23.0%) worked at the institute for 1-3 years and 43% was 21-30 years old.
2.Physicians’ understanding on healthcare quality improvement activities were as follows：evidence-based medicine (89.2%)、clinical pathways (78.2%)、5S (69.0%)、Quality Control Circle, QCC (56.4%)、Taiwan Quality Indicator Project, TQIP (48.6%)、Internal and external customer satisfaction survey (40.2%)、ISO accreditation (34.3%)、Benchmarking (31.4%) and quality improvement project (25.7%).
3.Most physicians (60.1%) responsible for healthcare quality improvement activities were assigned by the department head. Only 10.6% of physicians participated in the activities voluntarily.
4.The main barriers for participating health quality improvement activities are it takes a lot of time for quality agenda (65%), lack of resources (35.7%), and no incentive for one’s career (28.4%) were factors that discourage physicians from healthcare quality improving activities. Others were did not help the Professional upgrading (21.6%), lack of leader (17.8%).
5.According to physicians’ attitude on healthcare quality improving activities, seventy-five percent of respondents agreed or strongly agreed that physician engagement is important for quality improvement. Performance indicators (81.3%), institute-wide engagement (77.5%), and quality management center (73.5%) were other factors effective in improving healthcare quality. Those who believed these tools would improve healthcare quality were attending physicians and those who were older and senior, or responsible for administrative, teaching, or quality improvement activities.

Based on this findings, there were some suggestions：
1.Hospital managers can use TQIP as a tool for medical specialty to review and improve, through computerized management and confined with evidence-based medicine.
2.We should actively encourage physicians who are interested in and voluntarily provide the relevant resources to form culture, it will be helpful to implement total quality management.
3.A quality management center for system-wide approaches to execution is substantial for healthcare quality improvement. Physicians involve and be the central leaders to communicate and coordinate with other specialty.
4.The education of quality management can proceed by routine review of quality improvement and combine with the feedback data based on evidence-based provided by administrated department. People who were responsible for healthcare quality improving activities should involve and promote together.
5.Physicians who were responsible for quality improving project also had significantly related to healthcare improvement activities in clinical departments & the institute, and they play an importance part in it. In order to achieve institute-wide engagement in total quality management, we should be more often promoting and educational training.
6.The medical students’ education should subsume the concept of medical quality management and clinical applications into medical education obligatory courses. Incorporation of healthcare quality improvement activities with daily clinical practice would help to attract physician to improve healthcare quality.

並列關鍵字

physicians ； attitude ； healthcare quality improvement activities ； healthcare quality management

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