住院癌症病患之服務品質缺口分析

Quality Gaps Analysis for Inpatient Cancer Patients

許南榮(Hsu Nan-Yung)

指導教授 ： 龔佩珍 ； 蔡文正

亞洲大學/健康學院/健康管理研究所/碩士(2005年)

摘要

中 文 摘 要

服務品質缺口模式曾應用於許多不同醫療服務型態的研究探討，但尚無相關研究應用此模式於住院癌症病患的探討。本研究也應用重要性／績效分析法以及評量照護癌症住院病患的醫護人員顧客導向的認同度，作為改善照護癌症病患服務品質的參考，以提昇醫療的競爭力。
本研究以SERVQUAL量表問卷調查182位癌症住院病患、52位醫師和96位護理人員，發現醫師和護理人員對癌症住院病患醫療品質期望的認知皆低於病患對醫療品質期望(缺口一)，醫師在所有五構面(有形性、可靠性、回應性、保證性、同理性)落差值，都具有顯著性差異(P＜0.05)；而護理人員除了「有形性構面」無顯著性差異外，其他四構面，都具有顯著性差異(P＜0.05)，而在21項問項中，除了七項外，都具有顯著性差異。有關癌症住院病患對醫療品質期望與滿意度之落差(即缺口五)，發現癌症住院病患對醫療品質的期望皆高於滿意度。而癌症住院病患對醫療品質期望和滿意度落差值，發現所有五構面，P值皆＜0.05，而在衡量問項方面，所有21項問項，除了「有形性構面」中的「醫護人員儀容整潔體面」不具統計上顯著性差異外，其餘20項皆有顯著性差異。
有關分析影響醫護人員對缺口一的相關因素(複迴歸分析)，在醫師方面，發現學歷碩士以上(包括博士和碩士)和顧客導向的認同度評量二項，具有統計上顯著性差異；而在護理人員影響因素，只有顧客導向認同度評量一項，具有統計上顯著性差異。分析影響住院癌症病患期望與滿意度落差(缺口五)之相關因素(複迴歸分析)，發現影響因素包括性別，年齡，有無商業醫療保險，罹癌時間，癌症種類等，具有統計上顯著性差異。
使用重要性／績效的分析方法(IPA)，發現病患在五構面排序，對醫療品質期望(重要性)以「可靠性」排第一位，而病患的滿意度排行次序和重要性完全一致。經由IPA分析後，落於繼續保持區的構面包括「可靠性」、「回應性」、「保證性」；無任何構面落於迫切改善區和過猶不及區；落於非迫切改善區構面包括「有形性」和「同理性」。另外，醫師在五構面的排行，對病患期望的認知(重要性)，將「可靠性」排第一位，而自評滿意度亦是「可靠性」為第一位，「有形性」構面在重要性及滿意度皆排第五位。由IPA研究發現，落於繼續保持區的構面包括「可靠性」、「保證性」；「回應性」構面落於迫切改善區；落於非迫切改善區包括「有形性」和「同理性」；而無任何構面落於過猶不及區。護理人員在五構面的排行，對病患期望的認知(重要性)，將「可靠性」排第一位，在自評滿意度則以「保證性」排第一位。由IPA研究發現，落於繼續保持區的構面為「可靠性」；落於迫切改善區的構面為「回應性」；落於非迫切改善區的構面為「有形性」；而落於過猶不及區的構面包括「保證性」和「同理性」。
探討醫護人員對顧客導向的認同度評量的差異性，發現醫師以「注重病患治療後之持續追蹤服務」最高；護理人員以「醫療的競爭策略應建立在對病患需求的通盤了解」最高。相較護理人員，醫師顧客導向認同度評量較高，但只有「在醫療上，我會注重病患治療後之持續追蹤服務」這問項，二者有統計上顯著性差異。
如果直接由重要性／績效分析，發現癌症住院病患在五構面的醫療照顧品質評量上，並沒有任何構面落在迫切改善區，此點表示，整體而言，該醫學中心醫護人員對癌症住院病患的照顧有水準以上的醫療品質。然而針對缺口一和缺口五落差值，癌症住院病患對醫療品質的期望皆高於滿意度，而發現所有五構面和21項問項，也皆達顯著性差異，表示癌症住院病患對醫療品質有很高的期望。尤其有4項問項落入迫切改善區，包括「技術性純熟的專業服務」，「醫護團隊良好的溝通協調」，「提供最好的醫療照顧」，以及「重視病的最大利益」。值得注意的是這4項問項，只有「醫護團隊良好的溝通協調」一項，醫護人員同時認為屬於迫切改善區，可見醫護人員須一起努力以回應癌症住院病患的期望，以提昇醫療品質。
「以病人為中心」的照顧是現今醫療照顧的主流。在現今醫療高科技發展下，更應加強醫病之間良性的溝通，醫師在醫療上以科技為基礎，在態度上，要重視病人的感受和了解病人的完整性。具有高學歷的醫師，更應重視應用更好的醫療科技，對癌症病患的提供更好的醫療品質照顧。一般認為「護理人員以照護(Care)為主」，護理人員缺口一的落差值最大的為「鼓舞病患積極治療的勇氣」和「回答病患的醫療問題」二項。另外，「重視病患的最大利益」和「傾聽病患表達自己的感受」二項落差較大，可提供給護理人員，藉以改善照顧癌症病患的醫療品質。在缺口一的影響因素中，顧客導向的認同度在醫護人員皆具有顯著性差異。如何提升醫護人員顧客導向的認同度，對癌症病患提供更好的醫療品質照顧，是一重要的課題。

關鍵字

服務品質缺口模式 ； 住院癌症病患 ； 重要性／績效分析法 ； 顧客導向 ； 醫療品質

並列摘要

Abstract
Gap analysis developed by Parasuraman, Zeithaml, and Berry (PZB), followed by a SERVQUAL scale assessment is commonly used to quantify the functional quality of various health care service departments, however, few studies have investigated the service quality of inpatient cancer patients. In this study, we applied gap analysis and assessment by the SERVQUAL scale to investigate the service quality of inpatient cancer patients being cared for by physicians and nurses. In addition, the assessment was analyzed by Importance-Performance Analysis (IPA) and customer orientation was measured.
Expectations and perceptions of service quality of 52 physicians and 96 nurses caring for inpatient cancer patients and those of 182 inpatient cancer patients were assessed by a 21-item SERVQUAL instrument of PZB. We found that both physicians and nurses underestimate patient expectations (gap 1). Differences in gap scores between physician perceptions and patient expectations in all five dimensions of quality (tangibles, reliability, responsiveness, assurance, and empathy) were statistically significant (P<0.05). Additionally, with the exception of tangibles, differences in gap scores between nurse perceptions and patient expectations in the five dimensions of quality were statistically significant (P<0.05).
We found that the expectations of inpatient cancer patients were higher than their perceptions in all five dimensions of quality (gap 5); those differences between expectations and perceptions were statistically significant (P<0.05). Furthermore, the differences in expectations and perceptions in all 21-items except “physician-and-nurse appear neat” of the tangibles were statistically significant (P<0.05).
According to multiple regression analysis, both education level (Master degree and Ph.D. degree) (P=0.043) and the measure of customer orientation of physicians (P<0.001) had a different effect on gap 1; in addition, only measures of customer orientation of nurses had a different effect on gap 1 (P<0.001). Finally, gender, age, commercial medical insurance coverage, duration of disease, and sites of cancer had a different effect on gap 5.
IPA revealed that the priority of patient satisfaction and patient assessment of importance in service quality were concordant; the same result was found between physician satisfaction and physician assessment of importance. The dimension of “reliability” was ranked no. 1 by both patients and physicians in their satisfaction and assessment of importance. In addition, patients regarded no dimension of quality as being “concentrate here” or “possible overkill”; the dimensions of “reliability”, “responsiveness” and “assurance” fell in “keep up the good work”; and the dimensions of “tangibles” and “empathy” fell in “low priority”. IPA of physicians revealed that “responsiveness” fell in “concentrate here”; whereas “reliability” and “assurance” fell in “keep up the good work”. “Tangibles” and “empathy” were given in “low priority”. The dimension of “reliability” was ranked no. 1 in the assessment of importance of nurses; however, the dimension of “assurance” was ranked no.1 in their satisfaction. IPA of nurses revealed that “responsiveness” fell in “concentrate here”, “reliability” fell in “keep up the good work”, “tangibles” were “low priority”, and “assurance” and “empathy” fell in “possible overkill”.
Analysis of customer orientation showed that physicians regard “close attention is given to after-sales service in our hospital” as the highest measure; however, the analysis revealed that nurses regard “our hospital’s competitive strategy is based on a thorough understanding of our patients’ needs” as the highest measure. Physicians had higher mean scores than nurses in all 6-items of the customer orientation analysis; however only the item “close attention is given to after-sales service in our hospital” differed significantly between physicians and nurses (P<0.05).
“Patient-focused” care is the mainstream of the health care system. It is mandatory to strengthen closer communication between patients and caregivers, such as physicians and nurses. Caregivers should understand patients’ perceptions and provide whole person understanding. Furthermore, physicians with higher education levels should provide better quality care for cancer patients based upon the best available evidence. It is important that the concept of customer orientation should be implanted in the minds of both physicians and nurses.

並列關鍵字

Gap analysis ； Service quality ； Inpatient cancer patient ； Importance/Performance Analysis ； Customer orientatio

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