【作者】 邹婧睿；

【导师】 姚岚；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2012， 博士

【摘要】 1.研究目的本研究拟基于新公共管理和治理理论,借鉴国内外成熟的公立医院监督经验,并结合实证研究,在对我国公立医院监督现状进行全面了解的基础上,建立符合我国国情的公立医院多元监督模式并分析其实现策略,保障我国的公立医院在高效、法治、责任以及有序的环境中运行,为促进我国医疗卫生事业长期、持续、健康的发展提供决策依据和理论支持。2.研究方法本研究采用理论研究和实证研究相结合的方法。理论研究方面,本研究采用文献查阅的方法,形成多元监督模式的理论基础,获得国内外成熟的监督经验,以及我国公立医院监督概况及未来发展方向；并借鉴博弈论和成本效益分析的方法,分析多元监督模式中监控环节和评估环节的有效策略。实证研究方面,通过收集查阅公立医院监督模式改革典型地区(上海、海南)的公开信息及卫生年鉴数据,分析其改革模式的特点和初步成效,为本研究的多元模式探索提供经验。3.研究结果第一,改革典型地区经验分析。上海市公立医院监督模式的改革主要从监督管理整体网络进行,属于全局性的改革典型地区；上海市在新一轮的医疗卫生体制改革中,取得了工作效率提高、医疗费用上涨受控以及医疗公益性有所提升三大方面的成效。海南省的公立医院改革模式探索主要从医疗安全与质量的微观层面进行。成立第三方监督机构是海南省在公立医院改革中得重大和首要突破；海南省第三方医院评鉴模式的成效已经得到了公立医院、研究团体和卫生行政部门的认可和支持,其公立医院2011年在医疗质量、医疗效率以及医疗安全方面较2010年都有所提升,但由于针对医疗费用控制目标的监督模式并未同步改革,患者就医负担明显增加。因此,公立医院公益性的提升正需要从多个方面入手,针对不同的公益性目标,应建立相应的专业的监督机构加以管理,只有形成多元监督的模式,让每个监督机构都能充分发挥其相应的监督作用,才能真正实现对公立医院的监督总目标。第二,多元监督模式的内涵及主体界定。公立医院多元监督是强调多方协作、资源整合的一种监督模式。政府作为监督主导者,主要通过完成监督规则制定以及监督监控、评估及问责者的角色来实现对各种监督的整合及协调,并最终使我国多元监督模式形成以相对稳定的法律、社会监督和公立医院自我约束为监督主要力量的运作格局。我国公立医院多元监督模式中的监督主体应包括官方和非官方两大类机构,前者的监督行为贯穿完整监督所涉及的各个环节,而后者则主要负责监督的具体执行部分。第三,多元监督主体权责界定。政府在公立医院多元监督中应作为决策、执行和监督权分离的“服务型政府”发挥作用。医疗保险机构主要作为第三方付费者,对公立医院服务价格的公益性进行监督。第三方评估机构作为政府监督执行部门的委托代理者,主要负责对公立医院资产运营情况和服务能力的评估,其评估行为应被赋予一定的行政权威性和强制性,但不具有惩处权。行业协会作为政府监督的重要补充部门,主要从行业准入、职业规范、政策制定以及信息披露等多个方面实现对公立医院的监督行为,并具有非法律性惩罚权。新闻媒体和消费者协会则通过信息披露,代表社会公众协助政府监督以维护患者的合法权益,并为患者提供真实有效的公立医院服务信息,引导患者理性的就医及正确应对医疗纠纷。公立医院的自我约束机制的建立完善是多元监督模式的最终目标——公立医院严格自律。第四,多元监督监控与评估策略分析。监控策略方面：监控问责指标的设计实际上是提高了监督机构和监督人员的行为可问责性,本研究从目标评估、实现目标的途径、决策参与及决策审查这四个维度建立具体指标。建立科学的合理的核查制度以及系统运行的核查机构是降低合谋的外部保障,增加合谋成本、加大合谋查实惩罚及监督监控的舆论宣传力度,加强对公立医院的宣传教育工作都是降低合谋概率的有效手段。评估策略方面：在监督政策运行的初期,可以适当的增加监督成本,来提高公立医院监督效率,达到增加社会满意度的目的。政策运行的中期,也是监督效率水平的适宜区,这时应注意监督效率的变化动态,发现问题及时纠正,以保证最佳的监督效率水平。在监督政策运行后期,应防止监督过度,这时再盲目的增加公立医院监督成本,社会满意度也不会再有明显的提高。此时便不是一味增加成本就能满足社会需求,而是必须考虑新的监督政策出台了。4.政策建议第一,建立健全公立医院监督相关法律、制度体系。形成国家层面的公立医院监督模式框架顶层设计,建立包括公立医院运行法律制度、监督机构建立和运行法规、监督机构监督执行规则,以及监督问责法律规章等。第二,建立公立医院监督标准化体系。通过建立公立医院监督责任制,制定公立医院监督管理制度、操作规程及相关监督指标,规范监督行为使各个监督环节均符合有关公立医院监督法律法规和标准规范的要求,使监督者、被监督者均处于良好的有秩序的运行状态,最终达到公立医院自觉自律的理想目标。第三,建立“中国医院监督管理委员会”。“中国医院监督管理委员会”作为国家对医院进行统一宏观监督管理的核心机构,应由国务院直属授权,理论上主要包括医院监督政策制定委员会、医院监督监控评估委员会、医院监督问责委员会及医院监督信息委员会等职能部门,为公立医院监督体系提供宏观全面管理、协调,及合理的资源配置。第四,建立公立医院法人治理模式,完善“管办分离”。包括建立完善公立医院以理事会、医院管理层和监事会三大机构为核心的治理模式,并在此基础上,逐步转变行政理念、行政管理体制和卫生行政管理部门职能,构建“服务型政府”,明确政府职责,为公立医院多元监督模式的建立完善创造良好的体制环境。5.研究创新第一,本研究不仅仅局限于卫生部门或政府的视角,而是通过利益集团的分析,全方位的分析每一个可能对公立医院运行产生监督作用的主体。第二,本研究对监督环节进行整体的规划,结合前面确定的监督主体,从监督规则的制定到监督的评估总结、问责都有所涉及,并利用博弈论和成本收益分析的方法,重点对监督监控和监督评估策略加以研究,探讨公立医院多元监督监控及评估环节的理论策略,分析影响监督执行机构监督行为的因素及使监督效益最大化的手段,这在以往的公立医院监督研究中也是鲜有的。第三,通过分析政府在公立医院多元监督模式中的权责,本研究提出建立“中国医院监督管理委员会”(简称“医监会”)的设想,为公立医院监督体系提供能宏观全面管理、协调,及资源合理配置的核心机构。更多还原

【Abstract】 1. PurposeThe proposed study is based on the theory of novel public administration. By referring to the supervision experience of domestic and international public hospitals, with integration of case studies, the study is to establish the multi-supervision mode of public hospitals in China and analyze the implementation strategies, after a thorough review on current supervision situation in public hospitals in China. This proposed study aimed to help with the transformation of Chinese public hospitals to an efficient, law-regulating and responsible public service system, to provide theoretical support for the sustainable development of Chinese medical and health affairs.2. MethodsThe study utilized a method of integration of theory with case studies.On the theory part, by conducting literature review and consultation from experts, we obtained the theory basis for multi-supervision mode, supervision experience of international public hospitals, as well as the overview of supervision and future direction of Chinese public hospitals. We also used the game theory and cost-benefit analysis, to study the strategies for supervision and evaluation procedure in the multi-supervision mode.We conducted case studies by collecting literatures regarding to the public information and data from annuals of health and medication, from regions that have typical supervision mode in public hospitals (Shanghai and Hainan). We analyzed their characters of revolution mode and their initial advances in order to provide experience to exploring multi-supervision mode in this study.3. ResultsFirst, analysis of experience from regions with typical revolution. The revolution of supervision mode in public hospital in Shanghai was conducted from supervision and management of the overall network. It was a typical revolution region with whole situation. During the revolution they improved working efficiency, controlled increasing of medication service price, and promoted public beneficial effect of medication. The revolution mode exploration in Hainan was carried out from micro-aspects from safety and quality of medication. A major and primary advancement was the establishment of the third-party supervision agency. The efficacy of the evaluation mode in the third-party was accepted and supported by public hospitals, research institutions and health administrative government bodies. The public hospitals have a significant improvement in 2011 with regards to medication quality, efficacy and safety, compared with 2010. However, as there was no simultaneous revolution in the supervision mode for medical bill control, patients have an increase burden for medical bills. Hence, when it comes to the promotion of public beneficial effect of public hospitals, several aspects should be involved. A corresponding special supervision institution should be established based on different beneficial target. The realization of overall goals in supervision of public hospitals will only be achieved by formation of multi-supervision mode so that every supervision agency can play the corresponding roles in supervision.Second, the definition of connotation and main body in multi-supervision mode. The multi-supervision mode in public hospitals is a mode which emphasizes cooperation and integration of resources. Government, as the dominator of supervision, integrates and coordinates various supervisions by establishing regulations, supervising, and evaluating, with the ultimate goal to form the multi-supervision mode as a system that has relative stable laws, social supervision as well as self-regulation of public hospitals. The main body in the multi-supervision mode in public hospitals should consist of official and non-official institutions. The supervision from official institutions involves every procedure in supervision, whereas the unofficial institutions are responsible for execution of supervision.Third, definition of right and obligation of the main body of multi-supervision. Government should act as a service government for separation of the right from decision making, execution and supervision. Medical insurance companies, as the third party who pay the bill, should supervise the price for services in public hospitals. As an entrusted agency of government supervision, the third party evaluation agency should be responsible for evaluation of capital operating and service capability of public hospitals. The evaluation behavior should be authorized and mandatory, however, they should not have the right of punishment. Association of related business and industry, as the important supplemental agency for government supervision, should supervise the public hospitals on eligibility, standardization, policy-making, and news releasing. They should have the right of punishment out the side of the law. Media and association of consumers should defend the right and benefit for patients and provide accurate and efficient service information of public hospitals, by news releasing and assisting government supervision from the social public. They should also direct patients for rational medication-seeking and deal with medical issues rationally. The ultimate goal of multi-supervision mode, a strict self-regulation, is the accomplishment and establishment of self-regulation in public hospitals.Forth, analysis of supervising and evaluating strategies of multi-supervision. Supervising strategies:the design of quota of supervision and responsibility identification actually enhances the capability of responsibility identification of the supervising agency and staff. The study established the quota from evaluation of aims, approach for realization of aims, participation in decision-making, as well as census of decision-making. Establishment of census agency with scientific and rational census policy and systematic operation guarantees a lower collusion, a higher cost of collusion, a larger degree of punishment execution of collusion as well as supervision of public opinions. It is also efficient by strengthening the education for public hospitals. Evaluating strategies:during initial phase of supervising policy execution, we can increase the cost of supervision in order to enhance the efficiency of supervision in public hospitals and to social satisfaction. During the middle phase, which is the suitable region in supervising efficiency, the cost of supervision reaches the nadir with a relative stable. Attentions should be paid to the dynamic change of supervising efficiency in order to discover and correct potential problems so that the supervising efficiency remains optimal. During the last phase we should prevent from over-supervising. An increase in supervising efficiency in public hospitals will not necessarily result in an obvious crease in social satisfaction. By contrast, the cost of supervision will be increased dramatically. At this stage, enhancing the supervision efficiency will not satisfy the social needs but a new supervision policy should be considered to be published.4. SuggestionFirst, establish a system with related laws and policy for supervision of public hospitals. It is aimed to form a frame design in supervision mode for public hospital nationwide, to establish laws and policies for public hospital operation, setting-up and operation of supervising agencies, as well as rules for supervision execution for supervision agencies, and regulations related to supervision and responsibility identification.Second, establish a standardized system for supervision of public hospitals. By establishment of supervision responsibility policy for public hospitals, establishment of supervision administrative policy, standard operating procedures as well as related supervision quota for public hospitals, standardization of supervision behavior, each procedure involved in supervision will be fit with related laws and regulations, so that both supervisor and supervisee will work in an orderly manner to reach the ultimate goal of self-regulation in public hospitals.Third, establish the "Chinese Hospital Supervision Management Committee". Supervising Committee of Public Hospitals in China, as the core agency of supervision and administration of hospital by government, should be authorized by the State council. Theoretically, it consists of committee of policy making for supervision of hospitals, committee of supervision and evaluation for supervision of hospitals, committee of responsibility identification for supervision of hospitals, and the committee of information for supervision of hospitals. These committees will provide macro-supervision and coordination, resource allocation for the supervision system of public hospitals.Forth, establish the mode of juridical person management for public hospitals, and accomplish the separation of the executive management function and and operating. This includes establishment of administration mode consisting of administrative committee, leaders of hospitals, supervision committee in public hospitals. Based on this mode, changes should be gradually made on administrative theory, administrative management system and function of health administrative management in order to establish the "servicing government", with a clear definition of the duty of the government to provide a better environment for the multi-supervision mode in public hospitals.5. InnovationFirst, this study is not limited to the perspective of the health sector or government, but through the analysis of interest groups, analysis on every entity that might play a supervisory role in public hospitals from various aspects. Second, based on the overall planning of supervision procedure, with the integration of supervision core that is established earlier, various aspects, including formation of supervision regulation, evaluation of supervision, accountability, are involved in the study. We used game theory and cost-benefit analysis, with the emphasis on study of the supervision and evaluation strategies, to explore the theory strategies involved in public hospital multi-supervision and evaluation, to analyze the factors that influence the supervision behavior from supervision execution agencies, as well as the methods to maximize the efficiency of supervision, which has not been widely used in previous studies on supervision in public hospitals.Third, based on analysis of the right and responsibility of the government in the multi-supervision mode in public hospitals, we proposed to establish the concept of"" (referred to as ""), as the core authority, to provide supervision, coordination and resource allocation from various aspects for the public hospital supervision system.更多还原