署立醫院組織變遷之研究

A Study of Oraganizational Change in DOH-Affiliated Hospitals

李天申(Tien-Shen Li)

指導教授 ： 劉坤億

國立臺北大學/公共事務學院/公共行政暨政策學系/碩士(2008年)

摘要

署立醫院自1999年7月改隸衛生署之後，政府為提升其營運效率與效能，採行多元化經營策略，包括公民合營、委託經營、整併、改隸、法人化、成立區域聯盟等措施。然而，政府在推動署立醫院組織變遷（organizational change）的過程當中，明顯存有「路徑依賴」（path dependence）的現象。本研究採用文獻分析與深度訪談法，研析1999至2008年這段期間，衛生署推動署立醫院多元化經營的各種類型及相關個案。另外，本研究以「路徑依賴」為基礎，提出分析架構，除欲探討影響署立醫院營運的環境因素之外，同時也關注變遷的過程中，各行動者的態度、行為與互動關係，以及組織變遷的結果。全文的最後，進一步針對研究發現進行理論檢證，並提出實務與後續研究的建議。
研究結果顯示，署立醫院因束縛甚多而致使其績效不佳，以及面臨醫療環境的快速變遷，是政府推動其多元化經營的主要背景。另外，本研究發現，在推動變遷的過程中：
一、有政治力介入政策的執行，立法委員尤其活躍；
二、主管機關的官員異動頻繁且思維不ㄧ致，致使政策不夠穩定；
三、多數招標案的誘因不足，影響民間機構的投資意願；
四、署立醫院員工普遍不支持變革，但若由其他公立機構承接經營時，其阻力較小；
五、缺乏法制要件與配套措施，致使推動醫院法人化困難；
六、醫院及外部團隊主管的領導、溝通，以及主管機關的協調、執行力，是促成變遷的要件；
七、推動初期較著重於追求醫院的經營效率，但後來也逐漸重拾其公共價值。
最後，本研究也發現，縱然署立醫院組織變遷的過程中存有「路徑依賴」的現象，且一旦變革的幅度過於劇烈時，其成效可能會不如預期；然而，對於部分的變遷個案而言，其實多元化經營策略仍有一定的正面成效。

關鍵字

組織變遷 ； 新制度論 ； 制度變遷 ； 路徑依賴

並列摘要

The DOH-affiliated hospitals were attached to the Department of Health (DOH) in July 1999. For boosting the hospitals’ operating efficiency and effectiveness, the government adopted the diversified measures which include collaboration, out-sourcing, merger, alienation, corporatization and establishing district alliances. However, during the changing process, the phenomenon of “path dependence” was existed obviously. The research is based on document analysis and in-depth interviews to discuss the forms and cases of the diversified measures during 1999-2008. Furthermore, it takes the “path dependence” model as the analytic structure to interpret the environmental factors which affected the hospitals’ operation. Meanwhile, the research focuses on the actors’ attitudes, actions and interaction during the period, and it also notices the results of the change. At the end of the research, it examines the findings with the theory of path dependence and advances some recommendations for the policy and future researchers.
According to the findings, the background of the diversified measures was that the hospitals were rated a bad performance as a result of many constraints and facing the rapid change in Taiwan’s medical environment. Furthermore, during the changing process, the research finds that:
1. There was a certain political power (especially legislators) intervention in the policy-implementation.
2. The DOH officials were alternated frequently without consensus about diversified measures. Therefore, the policy was unstable.
3. Private organizations were not willing to invest in, for there was a lack of incentives in the most of public biddings.
4. Most of the hospitals’ employees opposed the change. Nevertheless, when the DOH’s management right and ownership of the hospitals were succeeded by other public organizations, the amounts of resistance were fewer.
5. There were no condition of legislation and insufficient complementary measures, so it was difficult for the hospitals to transform into corporations.
6. Leadership, negotiation, coordination and execution are the necessities for successful changes.
7. Initially, the measures were more emphatic on the hospitals’ operating efficiency; later, DOH attached incremental importance to public value.
Finally, in spite of obvious “path dependence” phenomenon and less-expected outcome resulted from radical changes, there are certain positive effects in some changing cases actually.

並列關鍵字

organizational change ； new institutionalism ； institutional change ； path dependence

參考文獻

楊志良（1993），《健康保險》。台北：巨流。

張睿詒（1999），〈精省後省屬醫療機構的組織再造與歸屬〉，《中華衛誌》，第18期，第1卷，頁1-2。

行政院衛生署（2001），《92~94年度中程施政計畫》。台北：行政院衛生署。

行政院衛生署（2004），《95~97年度中程施政計畫》。台北：行政院衛生署。

徐享達（2001），〈公立（營）機構績效不振因素分析—兼論署立醫院突破困境因應之道〉，《醫務管理期刊》，第2卷，第3期，頁47-59。