【作者】 李建涛；

【导师】 郑建中；

【作者基本信息】 山西医科大学 ， 流行病与卫生统计学， 2014， 博士

【摘要】 研究目的公立医院改革是新医改的核心和关键，大型公立医院又是公立医院改革的难点和重点。本研究从当前我国大型公立医院治理领域存在的主要问题分析出发，在对不同保健模式代表国家的大型公立医院治理进行比较分析的基础上，针对“政府全能”或“市场至上”的一元治理失效，借鉴经济学新制度学派的“多中心治理”思想，将“治理概念”延展至以大型公立医院为核心，囊括患者、医务人员、医院管理者、政府、医保机构及其他利益团体在内的整个利益交换系统上，拟通过构建既符合我国国情，又能实现利益相关各方共赢的大型公立医院治理模式，为促进我国大型公立医院持续健康发展、更好履行社会职能提供决策依据和理论支持。研究方法本研究主要采取了定性讨论和定量分析相互结合、理论探讨与实证研究相互印证的综合研究方法。首先，利用文献荟萃分析，尽可能系统地查阅收集有关大型公立医院的文献资料，通过对其进行定性和半定量的专题研究，借助“卫生系统宏观模型”从治理角度对大型公立医院现存主要问题，进行分析归纳和系统确认；其次，利用类型比较分析，对不同保健模式下世界有关国家大型公立医院的功能定位、费用补偿、管理体制和服务效能等相关情况，进行分析、比较、归纳，探讨其治理结构的构成、治理机制作用的发挥以及治理模式产生的初始条件等内在共性规律；第三，利用利益相关者分析，对大型公立医院利益相关群体进行识别分类，并通过分类组织焦点群体访谈的方式，完成对大型公立医院各利益相关群体能够付出并用于利益交换的“交易资本”和“交易诉求”的汇总；第四，选择山西省某三级甲等公立医院为聚落核心，采取从与其发生联系的各利益相关群体中按照一定比例选取个体的方式，组织问卷调查完成收集数据；第五，利用因子分析、结构方程技术，针对有关数据进行探索性因素分析和验证性因素分析，通过相互交叉证实完成大型公立医院治理模型的构建；最后，借助在大型公立医院治理中发达国家的现实做法和我国公立医院改革实例，对所构建的基于多中心思想的大型公立医院治理模式进行案例实证分析。研究结果1.大型公立医院治理领域存在问题的确认通过对“中国学术期刊全文数据库”、“中国生物医学文献数据库”、“万方医学网”等三大数据库中1998年到2009年的417篇文献的阅读与分析,系统归纳总结出我国大型公立医院治理领域存在问题共有70小类,按照问题系统宏观模型提示的子模，逐级归纳为医院内部系统和外部环境的6大类问题。研究认为产生系列问题的根源在于整个国家社会生产组织方式转变过程中，公立医院乃至整个医药卫生事业系统管理体制机制没有及时作出系统的结构性调整。当用于以规范大型公立医院利益相关各方交易行为的正式制度规则失效之时，由社会“潜规则”进行的需求空白弥补，就造成了系统总体交易成本增加、运行效率下降和矛盾冲突激化。因此，单从加强大型公立医院内部管理的微观角度，来推进公立医院改革所能取得的成效必然有限，必须从宏观、中观层次对大型公立医院治理模式进行重构。2.大型公立医院治理模式的国际经验比较按照科尔奈对世界医疗服务组织六大模式的归纳，分别选取英、德、美、新、加以及与我国同属发展中国家的墨、印等国，从功能定位、费用补偿、管理体制和服务效能等角度进行大型公立医院治理现状比较。研究发现：①各国举办大型公立医院大都定位于相对低发疑难病症的诊疗，而非多发常见疾病诊疗的服务规模扩大，区别仅在于是否能从制度上实现就诊人群的分流；②相对于发展中国家的政府包办大型公立医院，经济发展水平和社会成熟程度都较高的发达国家更多强调多元参与、协同治理，治理结构相对多元复杂，治理机制直接控制较少，手段相对丰富；③各国大型公立医院采取何种治理模式，能取得怎样的治理效果，不仅受到经济发展水平、社会成熟程度等“硬件”的约束，还与政府执政理念、国民价值取向、历史文化传统等“软件”息息相关。3.大型公立医院利益相关者识别分类和利益交换要素确定按照“投资专用性（或退出障碍）”和“是否存在交易型合同”两个维度，将包括政府、医务人员、医院管理者、患者、医保机构、药械厂商、相关行业专业组织、其他类型医疗机构甚至社会公众和大众媒体等大型公立医院利益相关者，界定划分为四种类型，并明晰其各自在构成大型公立医院医疗服务的各种契约交易中的参与方式和交易地位。在此基础上，以分别组织焦点群体访谈的方式，明确前8类利益相关群体能够付出并用于利益交换的“交易资本（专用价值）”和最希望保护的“交易诉求（核心利益）”。4.基于多中心思想的大型公立医院治理模式构建检验为探寻大型公立医院利益相关各方在就医诊治、医院运行、医疗付费、监督评价诸环节中可能存在的利益交换链接点，选择山西省某三级甲等公立医院为聚落核心，采取从与其发生联系的各利益相关群体中按照一定比例抽取个体的方式，组织问卷调查完成收集数据。运用因子分析和结构方程测量模型，在就医诊治、医院运行、医疗付费、监督评价四个环节共发现并交叉证实存在利益交换链接点19个。围绕医患间的诊疗合同，政府与医院、医生间的聘用合同，患者与医保、医保与医院间的医保合同等交易契约，构建完成了由就医诊治治理模型、医院运行治理模型、医疗付费治理模型、监督评价治理模型共同组成的基于多中心思想的大型公立医院治理模式。5.基于多中心思想的大型公立医院治理模式实证研究按照民法对契约要件构成的要求，从当事人意愿、订约所必要能力、标的、违约处理等角度，对大型公立医院利益相关各方存在达成交易契约可能的19个利益交换链接点逐一进行分析。在利用发达国家具体做法和我国公立医院改革案例完成实证研究的同时，具体提出包括推动政府治理角色转变、落实医院独立法人地位等的6条政策建议。主要创新点1.在研究对象选择上，将居于三级医疗体系顶端的大型公立医院治理问题作为公立医院改革研究重心，为下一步公立医院改革进入城市大型医院阶段后，医疗卫生改革部门的宏观决策制定、医院管理者的具体改革实践提供有益参考。2.在研究理念运用上，将“多中心治理”思想引入大型公立医院治理研究，拟探索出一条与单纯强调“政府全能”或“市场至上”不同，能有效减少以往单中心治理失效、适合我国国情的大型公立医院“善治之道”。3.在研究路径设计上，打破按照组织内外部划分进行治理模式研究的传统思路，通过对大型公立医院各利益相关群体在就医诊治、医院运营、医疗服务、监督评价四个环节中共同利益链接点的探寻，完成包括多中心的权力结构设计、多样化的治理结构安排和切实可行的治理举措在内的大型公立医院治理模式构建与验证。更多还原

【Abstract】 ObjectivesThe large public hospital is the focal point and difficult point of Public Hospital Reformwhich is the core and key of new medical reform. According to the irregularity of OmnipotentGovernment and Market fundamentalism, through analyzing the major problems in governanceareas of the large public hospitals, and comparing the governance models of the large publichospital between typical countries, the study absorbs ideas from Polycentric Governance ofNeo-institutional School, expand the concept of governance to overall interest exchange systemcentered in the large public hospital which consist of patients, medical staff, hospital managers,government, medicare offices, etc. It aims to construct a governance model of the large publichospital according with the situation of our country and achieving the interests of all parties,which could provide decision-making basis and theoretical support for the large public hospitalreform.MethodSThe study adopts the comprehensive research method which to combine qualitative analysisand quantitative analysis, to confirm each other by theoretical discussion and empirical research.Firstly, using the literatures induction and analysis as far as possible to collectsystematically the large public hospital of relevant literatures, and to carry out qualitative andsemi-quantitative research, we analyse and confirm to governance problems of large publichospital by the macro module special for health system.Secondly, using the types of comparative analysis to induce the relevant information aboutthe functional orientation, expense compensation, management system and service efficiency oflarge public hospitals in the typical countries, we seek the inherent law further of governancestructure, governance mechanism and initial condition about large public hospitals.Thirdly, using stakeholders analysis to identify the stakeholder groups of large publichospitals, we summarize Trading Capital and Trading Demands of the stakeholders which couldpay for exchange of interests through Focus Group Interview.Fourthly, selecting certain tertiary public hospital of Shanxi province as nucleatedsettlement, we organize questionnaire survey to collect data which the samples come from thestakeholders around the hospital. Fifthly, using factor analysis and measurement model of structural equation for exploratoryfactor analysis (EFA) and confirmatory factor analysis(CFA), we build the governance model ofthe large public hospital after cross validation.Lastly, using the case empirical study above the govern measures of the developed countriesand public hospital reforming examples of our country, we test and verify the large publichospital governance model based on Polycentric Governance.Results and Conclusions1. To confirm the governance problems of the large public hospitalTaking417literatures published from1998to2009on CNKI, CBM and WanFang MEDOnline as samples, we summarize70kinds of governance problems about the large publichospital, and squeez it into6kinds of problems which include to the hospital internal system andexternal environment step by step. The study finds that the root causes of problems lie in thesystem and mechanism of public hospitals not adjusting timely when it take place dramaticchanges in the social organization structure and production style of the whole nation. Whenofficial rules and regulations became invalid in regularizing transaction behaviors of the largepublic hospital stakeholders, that Hidden Rules filled space resulted in which the overall systemincreased transaction cost, decreased operating efficiency and intensified conflict. Therefore,only through strengthening the internal management of the large public hospitals frommicrocosmic angle, the achievement of Public Hospital Reform will be ineffective. We mustreconstitute governance model of the large public hospital from macroscopic and Madhyamikaview.2. To Compare the governance models of the large public hospital between typicalcountriesAccording to6modes of the world medical service organization by Janas Kornai, wechoose Britain, Germany, the United States, Singapore, Canada, Mexico and India as samples,and compare the functional orientation, expense compensation, management system and serviceefficiency of large public hospitals in the typical countries. The study finds that the aimestablishing large public hospitals by national governments are provision of diagnosis serviceand treatment service to the difficult and baffling diseases rather than the common disease. Thedifference is Whether they could shunt clinic population institutionally. The study also finds thatrelative to keep everything in governments own hand in the developing countries, the developedcountries are more emphasis on participation and cooperative governance in the large publichospitals governance that governance structure is relatively complex, direct control means of governance mechanism are less and indirect control means are relatively abundant. The studyfinds that which kind of management mode of large public hospital have something to do withthe level of economic development and social maturity, but also with the governance concept,value orientation, national historical and cultural tradition.3. To identify classification of the large public hospitals stakeholders and determinethe elements of exchange interestsAccording to the specific investment dimension and transactional contract dimension, thestudy identify the4types of stakeholder which include the government, medical staff, hospitalmanagement, medical insurance institutions, medical device manufacturers, patient, relevantprofessional organizations, other types of medical institutions, the social public and media, andto clear the means and position of exchange of them. By Focus Group Interview the study listTrading Capital and Trading Demands of the former8stakeholder groups which could pay forexchange of interests.4. To build and test the governance model of large public hospital based on PolycentricGovernanceIn order to explore the links of interest exchange of the large public hospitals stakeholdergroups in medical treatment, hospital operation, medical payment and medical supervision, weselected certain tertiary public hospital of Shanxi province as nucleated settlement, and organizequestionnaire survey to collect data which the samples come from the stakeholders around thehospital. Using factor analysis and measurement model of structural equation for exploratoryfactor analysis (EFA) and confirmatory factor analysis(CFA), the study found19links of interestexchange. Then, around the treatment contract between doctors and patients, the employmentcontract between government, hospital management and medical staff, the insurance contractbetween patients, medical insurance and hospital, we build the governance model of the largepublic hospital which include medical treatment, hospital operation, medical payment andmedical supervision.5. The governance model of large public hospital based on Polycentric Governance byempirical studyIn accordance with the law of contract elements, from the perspective of the will of theparties, the contracting capacity, object of transaction and Breach of the contract, etc.19links ofinterest exchange are analyzed one by one, and verify by the govern measures of the developedcountries and public hospital reforming examples of our country. In the last, the study offerpolicy proposal including to promoting the role of governance transformation, implementing the independent legal person status of large public hospitals, etc.Innovation1. In the choice of subjects, the study focus on the governance problems of large publichospital that is at the top of three-grade medical system, which could provide a useful referenceto decision-making institutions and hospital administrators.2. In the concept of study, the study takes polycentric governance into the governance oflarge public hospitals, in order to explore a Good Governance pathway which to be differ fromthe irregularity of Omnipotent Government and Market fundamentalism, and to avoid ineffectiveof monocentric governance formerly.3. In the research of design, the study break the traditional idea of governance in accordancewith the internal and external research division, and explore the links of interest exchange of thelarge public hospitals stakeholder groups in medical treatment, hospital operation, medicalpayment and medical supervision, reconsitute the governance model of large public hospital thatinclude the polycentric power structure, the diverse and feasible control measures.更多还原