【作者】 贾殿和；

【导师】 秦银河；

【作者基本信息】 第三军医大学 ， 后方专业勤务， 2010， 博士

【摘要】 伴随着国家军队建设科学发展和全面建设小康社会伟大事业的加速推进,干部保健工作的地位更加突出,国家军队对干部保健工作提出了新的更高的要求。与此同时,广大干部保健对象对身体健康和生活质量的关注程度也与日俱增,特别是在疾病早期处理、慢性病有效治疗和提高生活质量等方面的要求更加迫切,医疗保健工作面临新的机遇和挑战。军队干部保健对象由于身份、地位以及对国家军队贡献的特别性,决定了其在医疗需求、医疗满意等方面的特殊性,对医疗保健服务流程、质量和效率的要求更高,更加注重差异化的高标准服务和个性化的医疗满足,更加强调就医过程的顺畅高效和诊疗流程的有效衔接,更加注意人性化的体验和尊重需求的满足。如何根据军队干部保健对象的特殊医疗需求,有针对性地提供个性化、多层次的医疗保健服务,把党、国家和军队对干部保健对象的重视和关怀落到实处,成为各级首长非常关注、各级医疗机构积极研究的一个重大课题。在众多的探索中,军队某大型综合性医院无疑具有引领作用。作为中央保健基地,该院保健临床部在制度建设、硬件设施、人才队伍、流程管理等方面形成了非常突出的特色和竞争优势。经过长期的实践,逐步建立了以健康体检为基础,健康评价和疾病预警为核心,分类管理、有效干预、防治结合为手段,健康改善为目的干部保健对象全面健康管理机制,构建了适应干部保健对象多层次医疗需求的人性化全过程无缝隙服务流程。基于该院现有的医疗服务流程以及实践经验,运用国际上公认的衡量竞争优势的金标准——顾客价值理论,进行深入评价、挖掘并提取其蕴含的先进管理理论内涵,不仅对其他单位有很强的指导价值,更有利于引领国家、军队干部保健事业科学发展。目的:运用国际先进管理理论,构建干部保健对象医疗服务流程评价体系,对军队某大型综合性医院干部保健对象医疗服务流程进行评价研究,提出相应的建议。①构建基于顾客价值理论的干部保健对象医疗服务评价体系;②建立系统调研军队干部保健对象医疗服务需求特点和满意度状况的方法及标准;③对干部保健对象医疗服务需求和医疗服务满意度进行对应性双调研;④通过对军队某大型综合性医院医疗保健流程的评价研究,为建立军队保健工作持续竞争优势提供科学依据。方法:本文采用理论和实证研究相结合的方法。理论研究中,采用了文献分析法,通过系统阅读国内外相关文献,进行综合、分析、创新,结合专家咨询,最终构建出本研究的模型、指标体系和流程管理操作框架。实证研究中,依据干部保健对象医疗服务价值指标体系,设计形成了《干部保健对象医疗服务需求调研表》和《干部保健对象医疗服务满意度调研表》,随机选取2006年1月至2009年1月在军队某大型综合性医院保健临床部住院治疗的体系内200名离退休干部进行问卷调查,100名进行访谈,收集大量可靠的数据,并进行统计分析,探讨体系内干部保健对象医疗需求特点以及相对应的满意度状况,并针对满意度较低的医疗服务流程提出建设性的改进意见。结果:1.提出了干部保健对象医疗服务价值概念:干部保健对象医疗服务价值即为其感知价值,是干部保健对象对其医疗需求实现程度的认知。干部保健对象围绕其特定的医疗需求,在接受医疗服务的过程中,对一定关系期间的医疗服务和辅助服务实现其需求目标的贡献与相应的付出进行综合权衡后所做的整体性感知与评价,是感知利得与感知利失的权衡。其中,感知利得是干部保健对象从医疗机构提供的医疗服务中感知到的全部获益,包括核心利益、形式利益、期望利益、延伸利益;感知利失是干部保健对象感知到的为获取医疗服务所付出的全部成本,包括时间成本、生理成本、心理成本等。根据这一定义,干部保健对象医疗服务价值被分解为情景维度和等级维度。情景维度是指干部保健对象在认知和评价医疗服务的各种价值构成要素时要依赖一定的消费情景;等级维度是指医疗服务所提供的一系列不同的价值在干部保健对象心目中具有不同的重要性。2.构建了干部保健对象医疗服务价值构成模型、价值驱动模型以及价值指标体系,建立了基于顾客价值的干部保健对象医疗服务流程评价与管理操作框架。设计了干部保健对象医疗需求和满意度调研问卷,针对同类人群进行医疗需求和满意度对应性调研分析,根据调研结果对干部保健对象医疗服务流程效能进行总体性评价。3.调研结果表明,军队某大型综合性医院体系内离退休干部保健对象医疗服务需求呈现多元化趋势,在关注医疗技术的同时,对就医便利、出院随访、及时入院、受到尊重、保护隐私等的需求较高。满意度调研表明,干部保健对象在对现有医疗服务流程及产出总体满意度较高的同时,对出院随访、入院等待、伙食服务等环节满意程度较低。4.访谈结果显示,离退休干部对体检、用药、住院、健康宣教、随访等都有一定的诉求。关于健康体检,30%的访谈对象反映因年事已高到医院体检一次很累,希望实行分级查体制度,军队某大型综合性医院应该重点提供高端和疑难项目的检查,并负责分析检查结果,其他常规检查项目可由所在单位医疗部门完成。25%的访谈对象要求每年住院3-7天进行专门查体或每2年住院1次查体。15%的访谈对象希望查体发现的问题或需要复查的项目应该有非常清楚的记录并告知本人如何处理,避免盲目投医。关于用药,26%的访谈对象要求对已确诊的老年慢性疾病如心脑血管病和代谢性疾病如糖尿病等,适当提高门诊用药档次。关于住院,45%的访谈对象反映住院难,虽然院方采取了一些措施,近期有好转,但没有根本解决。75%的访谈对象希望1周内能够住上院。对诊疗过程,80%的访谈对象希望医生提供详细的解答和耐心的指导,希望医患之间沟通,特别是医生要主动向病人讲解治疗方案和指导用药,耐心解答病人提出的问题,对病人要表现出细心和关怀的态度;40%的访谈对象希望护士在发药的同时也应主动向病人介绍药品的服用方法与注意事项。关于保健知识,76%的访谈对象渴望老年健康保健知识讲座和有关的健康咨询;37%的访谈对象希望科室多进行一些涉及本科室特色以及业务范围的知识宣传。关于院外随访,83%的访谈对象希望在家中得到随访、康复和后续治疗上的指导。另外,20%的访谈对象希望医院重视交叉学科的疾病诊治问题,希望及时组织专家会诊。结论:1.顾客价值理论可成功引入并指导干部保健领域的实践。我国对医疗服务顾客价值的研究还处于探索阶段,并无系统的理论与应用研究。我们尝试将这一理论引入干部保健领域,并初步建立了保健对象顾客价值理论及评价体系。2.医疗需求与满意度双调研方法能够科学地分析判断干部保健流程的保障效果与薄弱环节。干部保健对象医疗服务价值指标,是医疗服务消费各环节与诸多接触点的关键控制与感知指标,既是干部保健对象医疗服务价值的驱动因素,也是其价值需求要素,同样也可以作为价值满意要素。顾客价值指标体系经过演绎可用作顾客需求调研和满意度测评的指标。3.离退休干部保健对象医疗需求呈现出多样化趋势,就医便利、医患沟通、及时入院、受到尊重、隐私保护、知情选择等期望服务需求和自我实现需要已成为军队高端人群的基本性需求要素。与专家咨询和针对其他人群进行的调研结果不同。分析原因:一是某军队大型综合医院诊疗技术水平较高,二是研究对象在高水平诊疗服务得到充分保障的基础上,服务需求进一步提高,三是公费保障。4.离退休干部保健对象对现有医疗服务流程整体表现比较满意。其中,对服务态度和就医环境满意度最高,对治疗效果和受到尊重的满意度比较高,对出院随访满意度较低,对入院等待和饮食服务不够满意。需要引起高度重视,进一步研究存在的具体缺陷和原因,提出改善提高的方法。5.某军队大型综合医院医疗服务流程表现出整体上的卓越保健效能和具有引领作用的突出竞争优势。本研究结果显示,该院现有医疗保健模式与流程,完整体现了国际先进管理理论的要求,代表了具有中国特色的干部保健的最高水准。更多还原

【Abstract】 With the scientific development of building national military and the fast promotion of building a well-off society in an all-round way, the status of cadres’health care is more significant and national militaries put forward a new and higher claim on the health care. Meanwhile, more and more cadres pay attention to their health and living quality increasingly, especially raising an emergent claim on early treatment for diseases, efficient treatment for chronic diseases. Under the circumstances, medical health faces new opportunities and challenges. The characters of military officers’statuses and their contributions to the country determine the specialty of their needs and satisfaction of medical care, which leads to higher requirements of service procedures, quality and efficiency of medical care. The officers emphasize different high-level services and individual medical satisfaction, smooth and efficient process of hospitalization, effective connection between diagnosis and treatment, human experiences and the degree of satisfaction. It is an important subject heads at all levels stress and medical institutions research actively how to offer individual and multi-level medical care services and to implement national and military emphasis and solicitude in real earnest basing on officers’special requirements. Among researches, a large army general hospital heads undoubtedly. As the health base of the central government, the clinical division of the large army general hospital has formed its characters and strengths in systemic establishment, hardware equipment, talent groups, procedural management and so on. After long-term practices, it has set up an over-all healthy management mechanism and structure human service procedure meeting different demands, taking health and physical examination as the base, healthy evaluation and disease alarm as the kernel, sort management and effective intervention and combination of prevention and care as the methods, healthy perfection as the target. Deeply summing and researching the practices not only guides other institutions also guides scientific development of the health care.Objects:To offer health care services out of the officers’expectations and create health strengths by evaluating the overall effectiveness of the procedure military officers get health care services with advanced international management thoughts and analyzing the characters of health demands and the satisfactory requirements for efficient procedure of health care from the angle of cadres.1 to build value model and index system for military officers and make theoretical references for related researches on the cadres’health care, basing on deeply deducting the advanced international theories such as customers’values, business process management and so on and on seeking advices from experts;2 to establish scientific methodology for improving the service procedure by structuring the management and operation of the health care service from the angle of cadres;3 to open up a new way for macro-evaluation and performance analyses of the health care by establishing a method of analyzing and evaluating the health procedure on the basis of researching the health demands and satisfaction;4 to get the characters of the health demands and the driving factors of satisfaction among the military officers systemically to offer practical evidences for the health care by analyzing the real evidences of the cadres’needs and satisfactions for health care.Methods:At president, there are no systemic theories and operations on researching the elements and driving forces of customers’values and business managements and evaluations in the theoretical field and there are few evidence researches, especially in the medical field, the researches are primary and limited on the whole and the theories don’t match the medical industry though many hospitals attempt to improve and perfect the service procedure,“taking patients as the kernel”. Many researches are not done and proved systemically from the relations between hospitals and medical service objectives, internal competitive environment in hospitals, contributive degrees to the objectives of the segments in the whole procedure of health services and different health demands at all levels. Therefore, we should not only prove and perfect the above factors in theory, but also apply the value theories and management thoughts in a certain field. In the dissertation, the writer combines the theoretical and practical researches, which assure the science and application of researches because the former offers premises and bases for the latter, while the latter raises evidences and supports. In the theoretical researches, the writer structures the model, the index system and the operation of researches by combining, analyzing, creating related documents home and abroad and by advising experts mainly with literature analyses. In the practical researches, the writer raises constructive suggestions for the lower satisfaction to reach the health services out of the cadres’expectations by selecting, collecting and analyzing the large and reliable data which are related with those who are diagnosed, treated in the clinic division of a large army general hospital in 2006.1 to 2009.1 with Questionnaire for the Health Service Demands of Cadres and Questionnaire for the Health Service Satisfaction of the Cadres.Results:1. In the dissertation, the writer defines the value of the health care objectives as the combination of the perception preference and evaluation which the health care objectives weigh the contribution and work of the health services and additional services during a certain period to realize their special aims in the scope of their certain health demands and selections under the circumstances of specific health services. It is the balance of the perception advantages and disadvantages in which perception advantages refer to all of those benefits the health care objectives obtain in the health services, including kernel benefits, tangible benefits, expectative benefits and extending benefits, while perception disadvantages refer to all of the costs that health care objectives pay for getting health care services, covering currency costs, time costs, physiology and psychology costs. According to the definition, the value of the health objectives are divided into scene dimensions and level dimensions. The former refers to the health objectives rely on certain consumption scenes when they recognize and evaluate all elements of health service values and the latter refers to the different values medical services provide have various importance from the angle of health objectives.2. On the basis of theoretical deduction, the writer raises value model of the health objectives and value index system and structure the management and operation of the service procedure from the angle of the customers’ values, combining the health care practice. First, the writer structures the index system of evaluating the objectives’ values, according to which the writer deducts the research indexes on the demands and satisfactions of the objectives’ health and analyzes the demands and satisfactions, whose analyses shows the overall evaluation of the procedure operation. The writer redesigns or perfects the procedure to meet the medical demands of the cadres on the basis of the evaluations. There are two activities in the frame: one is the analyses of factors driving the objectives’ values and the other is the evaluation of the medical service procedure, which will show the conditions of realizing the expectations pf the medical services and meet various demands for medical services.3. The results of the researching the demands for medical services indicate that the demands for the medical services tend to be diversified. At the same time the medical technology is paid attention to, demands for the convenience of hospitalization, follow-up treatment, respect and privacy protection are higher while the results of researching the satisfaction of the medical services show that the retired cadres in the system are not satisfied with the food, hospitalization, treatment and so on at the same time they are satisfied with the overall services highly.4. The results of the deep conversations with the health objectives show that some cadres claim the examination, pharmacy, hospitalization, health propaganda and education. There are 30 retired cadres claiming the examination is tiring, wishing the medical institutions will set up a mechanism to examine the cadres at different levels and suggesting that the large army general hospital should examine important items and be responsible for the analyses while the other items such as blood tests, type-B ultrasonic, chest x-rays can be examined by other divisions or institutions. Also 25 cadres wonder whether they can hospitalize for examination in 3-7 days a year or once two years. 15 cadres wish that diseases from the examinations or items for reexamination should be informed clearly to themselves, avoiding seeing wrong doctors. On pharmacy, there are 26 retired cadres reflect that the pharmacy for military cadres should be turned into local control and the pharmacy for the diseases diagnosed such as heart attacks, diabetes should be increased to a higher level in the clinic. On hospitalization, there are 45 retired cadres claim that the hospital doesn’t solve the difficulties for hospitalization at all though some measures have been implemented. Most interviewees wish that they can hospitalize within one week. On the procedure of diagnosis and treatment, 80 cadres wish that doctors can offer detailed answers and patient guidance, good communications between medical staff and health objectives, especially that doctors can actively explain the treatment plan guide pharmacy, answer the patients’ questions carefully and show their care to the patients. They also wish that the nurses will actively introduce the knowledge about medicines to the patients when they distribute the medicines. On the information of health care, 76 retired cadres are eager for knowledge lectures of the aged health care and related advices. They expect the divisions can do more propaganda and education related their own characters. Besides,20 retired cadres wish the hospital can stress the diagnosis connected with different divisions and organize experts’ consultation in time.Conclusions:1. As the health care base of China’s central government, the clinic division of the army general hospital has reasonable overall procedure of the medical services which are presented by:(1) the idea and management of the above procedure conform to the theory of customers’ values and the advanced international requirements of the business management, and also it presents the highest standard in the cadres’ health care, typically combining advanced international theories and management practices of modern health care.(2) the procedure can provide individual full-set medical services for the cadres on each link such as clinic, examination, treatment, hospitalization, follow-up visit and so on. Each division can connect with another smoothly, create values out of the cadres’ expectations, meet the cadres’ demands for medical services and win the cadres’ confirmation fully.(3) the outstanding health benefits created by organizations, positions and responsibilities, regulations, processes and coordination between divisions related with the procedure of the medical services can make references for the other institutions.2. The demands for the medical services from the cadres in the clinic division tend to be diversified. Under the preconditions of medical technology, they pay much more attention to the hospitalizing conveniences, diagnosis and treatment in time, respect, awareness, and follow-up treatment, which indicates that the people are fully confident in the level of the medical technology in the division. They fully represent the specialty of these cadres who are unlike other people taking medical technology as their first choice.3. At the same time they are highly satisfied with the overall medical services, the retired cadres in the division are not satisfied with the follow-up visit and ask for strengthening the follow-up visit and treatment, which shows that these retired cadres are eager to be visited, educated and guided for recovery and treatment at home because they are aged and have more chronic diseases.更多还原