【作者】 亓慧；

【导师】 李士雪；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2014， 博士

【摘要】 随着医疗体制改革的不断推进,公立医院在整个医疗服务体系中的主体地位以及人们对公立医院明确的政府性、公益性等法律属性的认可度越来越高。公立医院的运行效率影响着医疗行业的运行效率和质量,影响着为人民群众提供医疗服务的效率和质量。因此,建立公立医院绩效评价制度,推进医院质量管理,对增强医院的竞争力,提高医院服务社会的能力,实现服务对象、医院和社会三方共赢的局面具有重要的推动作用。研究目的和意义我国新医改于2009年开始实施,推行公立医院改革是新医改方案确定的重点改革内容之一。公立医院面临的挑战包括几个方面,一是在市场经济下,公立医院要面对国外资本、民营资本进入医疗市场的冲击；一方面要在政府投入不足的情况下保持公益性；第三方面是医患关系紧张,患者期望值的不断提高,可以自由选择医院、医生；还有来自医院内部员工价值观、工作压力带来的挑战。作为以我国医疗服务体系的主体,公立医院改革好坏直接关系到医改的成败,面对挑战,建立科学合理的公立医院的绩效评价体系,提升医院管理绩效管理水平可为医改指引方向。尽管国外有关医院绩效评价的理论和实践内容丰富、体系全面,也值得借鉴,但其理论体系的应用背景与我国不同,医院也不全是公立性质,公益性、公平性和社会责任体现不够,不能简单套用。从国内研究资料来看,现行的绩效评价体系研究不系统,随意性大,对几个主要质量指标的数量很关注,对过程指标的定性研究缺乏,对评价指标体系的通用性考虑欠缺。另外,绩效评估体系越来越注重公平和公益性,尤其是公立医院的绩效评估,与它的社会功能是密不可分的,要体现其社会功能和社会目标,就应该把公平和公益放在首位。采用什么样的绩效模式最有效,什么样的评价体系才不失偏颇,还应该从医院发展战略出发。公立医院的发展战略首先应该是在市场经济的大环境下,保持公益优先和先进性的原则,统一全院职工思想,加强全过程管理,为保障人民身体健康、提高全民族的身体素质不断追求卓越,使医院永远处于人民的满意之中。随着质量管理标准和绩效评价方法的发展,评价组织和评价方式逐渐增加,医院选择评价标准和评价体系的空间也更大。“卓越绩效模式”是全面质量管理标准的实施细则,又以绩效评价准则为基础,包含了质量管理对过程的监督,也包含了绩效管理对结果的评定,强调质量绩效的贡献和系统整合,重视系统的管理思想、以顾客为中心的理念和可持续发展的原则,扩展了社会责任的内容,是被公认的经营质量的国际标准。以卓越绩效准则为基础的卓越评价成为全世界企业、组织共同的行动和竞争平台,这是发展的趋势。作为世界医院的一部分,中国医院参照国际评价准则,参照各国医院管理评价方法,研究和探索一套符合我国国情和卫生事业发展规律的绩效评价办法,对推进公立医院改革,提高医院服务质量,促进医疗卫生机构的健康发展,具有现实意义。研究内容以国内外医院绩效管理的比较研究和卓越绩效评价理论框架为基础,从系统的观点出发,立足整体,把医院活动组织过程作为一个复杂系统来研究,按照按系统工程的理论分析医院绩效评价过程。借鉴国外基于卓越绩效准则改进管理体系的理论和方法和国内企业推行准则的经验,分析准则的内涵与外延与其他质量标准的区别,论证卓越绩效准则用于我国医院绩效评价的可行性和意义。通过理解卓越绩效准则的核心价值观,提出指标体系的设计原则,在卓越绩效准则框架下草拟初级备选指标体系,通过专家咨询对初级指标进行筛选,并对最终的指标体系确定指标权重。了解青岛市综合医院的基本情况；对被调研医院财务指标进行分析,减少评价指标的数量和信息重叠；实地调研医院的患者、员工满意度,并分析患者满意度需求与影响医疗服务质量的过程之间相关程度,找出对满足患者需求贡献最大的措施,进一步完善医院质量控制过程,指导医院各部门的工作；对医院综合绩效进行评价,验证所建立的评价指标体系对样本医院的绩效评价的价值,为卫生行政部门提供改革参考和依据。研究结果1.系统性研究了我国医院绩效评价的发展和研究现状,针对目前医院绩效评价存在的问题,将系统理论思想引入医院绩效评价中,提出借鉴国外医院和国内优秀企业卓越绩效模式经验,在医院绩效评价中学习和导入卓越绩效模式的可行性。2.依照卓越绩效准则的评价框架,构建了医院绩效评价的三级指标体系,采用因子分析方法对医院财务状况的10个因素进行了分析,提取了4个潜在变量,建立了医院财务指标综合评价的方程模型,得到医院之间的排名情况,有效地减少评价指标的数量,消除指标间的信息重叠,减轻评价的工作量；通过被研究的9所医院的1800名门诊和住院患者、360名医生和护士满意度的调研,对得到的数据进行了分析；利用质量功能展开工具分析患者满意度需求,通过构造“医疗过程控制”和“医疗质量控制”两级质量屋展开,将患者满意度需求嵌入到医疗全过程当中,经数据分析处理后找出对满足患者需求贡献最大的措施,从而完善医院质量控制过程。讨论了具有语言评价信息的综合评价方法在医院卓越绩效评价问题中的应用,并在实证分析中进行了医院整体绩效的研究。3.从医院的整体评价结果来看,调研的9家医院绩效评价等级都在“中等”和“比较高”之间,略高于行业“中等”的平均水平。医院评分较高的是“测量、分析和知识管理”“过程管理”,在“员工”和“顾客与市场”一级指标上得分均较低,医院之间综合绩效的差距主要体现在“战略”一级指标上。研究结论1.从系统的观点出发,把医院活动组织过程作为一个复杂系统来研究,以系统的思想分析医院绩效评价过程,可以立足整体,全面评价和改善整个工作过程,以实现综合最优。2.虽然国内医疗机构目前尚无一家医院获得中国质量奖,研究人员也很少使用卓越绩效评价医院绩效,从文献资料看,研究也多以综述性研究为主。分析表明卓越绩效准则及核心价值观与目前医院绩效评价存在的短板可以进行结合,卓越绩效准则在国外医院和国内企业的应用经验对我国医院的绩效评价、经营管理和持续的发展能起到很好的指导作用。3.以卓越绩效为基础,按照指标设立原则并筛选的指标体系,符合医院绩效管理的形式和规律,以系统工程方法分析相关指标和综合绩效获得了很好的效果,增强了指标体系的可操作性,具有广泛的应用价值。4.调研的医院对市场的把握不够,没有或者较少分析市场占有率,对员工、患者满意度的分析少,另外对媒体的关注也缺少足够的敏感性。医院之间综合绩效的差距主要体现在“战略”上,医院之间有待互相学习。A医院在领导、战略、信息化管理、过程管理等方面表现突出,充分反映了医院对管理的解析,发展思路清晰,A医院的做法和经验可向全市或更大范围推广。创新点本文系统性研究了我国医院评审的发展和医院绩效评价的研究现状,针对目前存在的问题,提出借鉴国外医院和国内优秀企业卓越绩效模式经验,在医院绩效评价中学习和导入卓越绩效模式的可行性和意义。利用质量功能展开工具分析患者满意度需求与影响医疗服务质量的过程之间的相关程度,经数据分析处理后找出对满足患者需求贡献最大的措施,为改进医院质量控制过程提供依据。依照卓越绩效准则的评价框架,构建了医院绩效评价的三级指标体系,采用二元语义信息决策分析方法进行了医院卓越绩效综合评价评价的实证分析,分析方法可作为卫生行政部门推行卓越绩效的参考。不足国内对卓越绩效模式在医院的应用和研究还处于起步阶段,学术研究不多,同时推行卓越绩效模式的医院少之又少,缺乏实践案例。卓越绩效模式强调的是“系统的视野”,但卓越绩效模式的框架还不够系统化,在构建绩效评价指标体系时,未能清晰的展示标准的各类目、指标之间的逻辑关系,在“过程”和“结果”的对应关系上还不够系统。这些也影响了本文对卓越绩效模式与医院结合更深入的研究,未来如果深入跟踪实践卓越绩效模式的医院或者成功的案例可进一步总结研究。由于医疗卫生行业数据的不规范、不完备,或者对指标体系中有些定性指标的理解不同,有些资料收集不是实时采集获得,数据的准确性存在风险；限于数据的可获得性,未能收集不同时间段的纵向数据,不能显示这些指标动态变化对综合绩效的影响；采用其他更好的、简易的综合评价方法和本研究采用的语音评价信息处理方法如果能得出一致的结论,将使研究结果更客观。更多还原

【Abstract】 With the advancement of medical system reform, the dominant position of public hospitals in the medical service system, governmental and public welfare of clear legal attribute recognition is higher and higher. The running efficiency of public hospital affects the operation efficiency and quality of health care industry, influence on the efficiency and quality to provide medical services for the people. Therefore, the establishments of public hospital performance evaluation system plays an important role, in promoting the hospital quality management, enhancing the competitiveness of the hospital, improving the hospital’s ability to serve the society, and realizing the service object, hospital and society tripartite win-win situation.PurposeNew reform in our country started in2009, and reform of public hospitals is one of the key content of the reform scheme in the new reform. Public hospitals are faced with the challenges include several aspects. One is under the market economy, the public hospital to face the impact of foreign capital, private capital into the medical market. On the one hand, to maintain its public welfare in the case of insufficient government input; the doctor-patient relationship is nervous, patient expectations continue to increase, and to choose the hospital and the doctor is free. Another aspect is from the hospital staff values and challenges of working pressure. As the main body of our country medical service system, the reform of public hospitals is good or not directly related to the success or failure of reform. In the face of challenge, establishing scientific and reasonable public hospital performance evaluation system can enhance the level of hospital management performance management and direct health care reform.While abroad on the theory and practice of hospital performance evaluation is rich in content and comprehensive system, is also worthy of reference, its application background and the theoretical system of our country is different. The hospital is not all the public properties, commonweal, equity and social responsibility is not enough, so it can’t be simply copied. From the domestic research materials, the current performance evaluation system of research system is randomness, and we pay close attention to quantitative indicators, lacking of qualitative indicators process research, and commonality of evaluation index system. In addition, the performance evaluation system is more and more attention to fair and public welfare, especially public hospital performance evaluation. And its social function is inseparable; you should put a fair and public in the first place. It is necessary to decide the most effective performance model or the overall evaluation system from the hospital development strategy. The development strategy of public hospital should be in the environment of market economy firstly, keeping the principle of public welfare and sophistication, unified floor worker thought, strengthen the whole process of management, improving the physical quality of the whole nation and people’s health, making the hospital forever in people’s satisfaction.With the development of quality management standards and performance evaluation method, evaluation organization and evaluation way increase gradually, and hospital enlargers choice of evaluation standard and evaluation system.\"Performance excellence model\" is the detailed rules for the implementation of total quality management standard, and on the basis of performance evaluation criterion, including the supervision of the quality management of process, the performance management evaluation of the results, the contribution of emphasis on quality performance and system integration, the system of management thinking, customer-focused concept and the principle of sustainable development, extending the content of the social responsibility, and it is considered the management quality of international standards.On the basis of performance excellence principle, evaluation becomes competition platform in the operation of enterprises and organizations around the world and, and this is the trend of development. As a part of the hospital, to research and explore a set of accord with China’s national conditions and health law of development of performance evaluation methods, to promote the reform of public hospitals, to improve the quality of hospital services, and to promote the healthy development of medical and health institutions hospital in China, has a practical significance reference to the international criterion and the hospital management evaluation method.ContentBased on comparative study of hospital performance management at home and abroad and theoretical framework of performance evaluation as a foundation, in the viewpoint of system, based on the whole, the hospital process is a complex system and hospital performance evaluation can be analyzed by the theory of systems engineering. Drawing lessons from foreign theories and methods based on excellence performance standards to improve the management system and the domestic enterprises experience to implement guidelines, and the different of the connotation and denotation of difference from other quality standards, the thesis demonstrate excellent performance criteria for hospital performance evaluation of the feasibility and significance of our country.By understanding the core values of excellence performance standards, the thesis puts forward the design principle of index system; draws up elementary index system of alternative in the framework of performance excellence, filters through expert consultation to primary index, and determines the index weight of the final index system. Learning the basic information of Qingdao general hospital; Analyzing of the research hospital financial index to reduce the number of evaluation index and information overlaps; Field surveying of hospital employee and patient satisfaction of demand and influence in the process of medical service quality to look up most contribution to meet the demand of patients and complete the hospital quality control process to guide the work of the hospital departments; the thesis evaluates hospital comprehensive based on established evaluation index system, verifies the value of the performance evaluation to the sample hospitals, and provides reference and basis for the reform of the administrative department of public healthResults1. The thesis systematically studies the development and research status of hospital performance evaluation in our country aiming at the problems of hospital performance evaluation, introduces system theory idea in hospital performance evaluation, and put forward the feasibility of the import and learning performance excellence model reference foreign hospitals and domestic excellent enterprise performance excellence mode experience.2. According to the evaluation framework of performance excellence criteria, the thesis builds the tertiary hospital performance evaluation index system, analyzes ten factors of the hospital financial status with factor analysis method, extracts the four variables, and potential equation of hospital financial index comprehensive evaluation model is established between the hospital rankings. It effectively reduces the number of evaluation index, eliminates information overlap between indicators, lighten the load of the evaluation. By research of1800outpatient and inpatient,360doctors and nurses’satisfaction, the thesis analyzes the data. With QFD tools the thesis analyzes patient satisfaction, and by constructing\"medical process control\" and\"medical quality control\" two levels of quality house, it embers the patient satisfaction demand of whole medical process and find the measures of most contribution to meet the demand of patients, so as to improve the hospital quality control process. It discusses the comprehensive evaluation method with linguistic assessment information in the hospital application of excellence performance evaluation, and studies the whole performance of hospitals in the empirical analysis.3. From the perspective of the overall evaluation results of the hospital, the research find nine hospital performance evaluation level in\"medium\" and\"high\",\"medium\" slightly higher than the industry average. Hospital ratings are higher\"measurement, analysis, and knowledge management,\"\"process management\", the\"employees\" and\"customer and market\" in the primary indicators score is low, the hospital mainly embodied in the comprehensive performance of the gap between\"strategic\" level indicators.Conclusions1. From the viewpoint of system, the research looks the hospital activities organizational process as a complex system to study. The idea of system analysis of hospital performance evaluation process can improve the whole working process of the comprehensive evaluation in order to realize the integrated optimal based on the whole.2.There is no hospital medical institutions have quality prize in China, few researchers use excellence performance evaluation of hospital performance, from the literature, the study is also given priority to with sex are reviewed. It shows that excellent performance criteria and the core values and weaknesses existing in current hospital performance evaluation can be combined, and that excellent performance criteria in foreign hospitals and domestic enterprise application experience to our country hospital performance evaluation, management and sustainable development can have very good guidance function.3. On the basis of performance excellence, the thesis sets up index system of screening according to the form and law of hospital performance management, system engineering method is used to analyze the related indicators and the comprehensive performance and the good effect, obtained.The method enhance the operability of the index system with extensive application value.4. The hospitals researched grasp of the market is not enough, there is no or less analysis of the market share, the analysis of the staff, patient satisfaction, less in addition to the attention of the media are lack of sensitivity. Hospital comprehensive performance of the gap is\"strategic\", which to learn from each other for the hospital. A hospital in the leadership, strategy, information management, process management, fully reflects the hospital on the interpretation of the management, development train of thought clearly;A hospital’s practice and experience can be popularized to the city or the wider.Creative pointsThis thesis systematically studied the development of hospital evaluation in China and the research status of hospital performance evaluation, aiming at existing problems, and puts forward feasibility and significance of learning and importing the performance excellence mode reference foreign hospitals and domestic excellent enterprise performance excellence mode experience, and introduces the ideas of system theory for in hospital performance evaluation the first time.With QFD tools to analyze between the demand of patient satisfaction and influence in the course of the medical service quality, the thesis finds out most contribution to meet the demand of patients based on data processing, and provides the basis of improving the hospital quality control process.In accordance with the remarkable performance criteria evaluation framework, the thesis builds the tertiary hospital performance evaluation index system. The binary semantic information decision analysis method is used for hospital remarkable comprehensive evaluation of the performance evaluation of the empirical analysis, and the method can be used as reference for performance excellence by the administrative department of public health.InsufficientThe domestic application of performance excellence mode in the hospital and the research is still in its infancy and academic research is few, at the same time pursuing performance excellence mode of hospital is rare and lack of practical cases. Performance excellence mode emphasizes the system’s horizons, but the framework of performance excellence mode is not systematic, in constructing the performance evaluation index system, it failed to clear show the standard of the logical relationship within various orders, indicators, in the\"process\" and\"results\" on the corresponding relation. These are also affecting more in-depth research in this paper. In the future tracking practice performance excellence mode of hospital or successful case study can be further summarized.Due to medical and health industry data is not standard, incomplete, or understanding of index system in some qualitative indexes, some real-time data collection is not collected, and the accuracy of the data is on risk.Shall be limited to the availability of the data, it failed to collect the longitudinal data of different periods, so the impact of these dynamic changes of comprehensive performance indicators can’t show. If other better, simple comprehensive evaluation method is adapted to assess information and the conclusion is consistent with the binary semantic information decision analysis method, it will make the results more objective.更多还原