【作者】 王敏；

【导师】 郭强；

【作者基本信息】 第二军医大学 ， 社会医学与卫生事业管理， 2008， 博士

【摘要】 近年来,随着全军大联勤改革的全面实行,军队疗养院开始在联勤体制下运行,其管理方式、经营策略、发展空间和服务对象范围都发生了明显变化。新体制为疗养院的建设发展注入了蓬勃生机和活力,也为疗养院的建设带来了难得的发展机遇。随着新体制的开展,一些深层次的问题逐渐突显出来,如管理体制、机制、人才、疗治结合等方面的问题制约了疗养院的进一步发展。尽管目前对疗养院开展了一些研究,但对疗养院满意度与反应性评价、医务和管理人员培训及培训需求、工作满意度、疗养院运行现状、特勤疗养提供等方面的评估仍是薄弱领域,从全面、综合的角度出发进行系统的疗养院发展策略研究则较少。鉴于此,急需探讨和解决这些深层次问题的对策与策略,以促进疗养院健康持续发展。本研究在文献综述的基础上,针对疗养院发展中的热点、难点、空白点与薄弱环节,从需方和供方两方面出发,运用定性与定量相结合的方法收集了相关资料,对疗养院的发展现状及相关因素进行较为深入的剖析,发现其运作过程中存在的主要问题及原因以及影响疗养院进一步发展的关键因素,提出疗养院发展的政策建议。研究目的分析疗养院目前的运行现状,找出制约疗养院发展的相关因素。进行疗养院发展策略的系统研究,提出疗养院可持续发展的策略。研究内容疗养院满意度和反应性评价;疗养院人力资源现状;疗养院运行现状评价;特勤疗养相关研究;疗养院可持续发展策略研究。研究对象对军队16家疗养院进行相关调查。研究与分析方法在收集常规登记报告资料的基础上,采用定性与定量相结合的方法进行补充调查,同时利用检索工具收集相关的文献资料。定量调查包括:疗养院满意度和反应性、工作人员培训相关内容、工作满意、稳定性抽样调查、管理者培训需求评估调查、疗养院机构效率、特勤疗养情况等。定性调查包括:疗养院领导个人深入访谈,疗养院医务人员专题小组讨论,相关人员的选题小组讨论等。资料分析采用描述性研究与分析性研究相结合的方法,主要分析方法包括:描述性分析、多因素分析(如Logistic回归、因子分析等)、TOPSIS法、DEA分析、SWOT分析、情景分析、定性分析等。其中定性分析方法采用阅读过录文本、编码、属性归类、进行解释一系列定性分析步骤,对资料进行解读。主要研究结果本研究五个主体部分研究结果如下:一、疗养院满意度与反应性评价疗养员对疗养院的满意度总体评价得到的结果是大约93.06%的人是较满意或很满意的,总体评价满意度的平均得分为4.40,在所有项目中排名靠前,说明疗养院的满意度水平较高受到大多数疗养员的认可。医护人员的态度、就诊程序、景观疗养等几个方面的满意度较高,但医疗设备、后勤保障等项目满意度较低。反应性各项评价中尊严的评价较好,92.59%的被调查者认为很好或好;在自主性选择方面有81.48%的被调查者评价是很好或好;疗养院的保密性工作在疗养员中得到高的评价,评价好或很好的有85.19%;关于“交流”的评价在被调查者中有87.04%的人认为很好或好;及时关注方面的评价是51.39%的人评价好或很好;对基础设施方面的评价有65.86%的疗养员认为疗养院的住宿条件很好或好,有74.60%的疗养员认为疗养院的体检室条件很好或好,85.27%的疗养员认为疗养院的环境清洁程度很好或好,对疗养院的设施配置有51.22%的疗养员认为很好或好,疗养院基础设施方面主要体现在设施配置和住宿方面的评价相对较低。由于受疗养任务特点制约的影响,选择性一项中的疗养员是否有权选择疗养机构评价较低,只有26.86%的调查对象能够选择疗养机构;选择性总体评价有49.07%的人认为很好或好;社会支持的总体评价为51.03%的人认为很好或好。结合反应性8个因子的评价得分可以看到疗养院在反应性方面评价较好的是尊严、自主性、保密性、交流、及时关注、基础等项目;评价较低的是选择和社会支持等项目。在分别对满意度和反应性进行调查研究的基础上运用统计的方法将反应性各项目与总满意度之间的关系进行了进一步探讨。反应性8个子项与满意度均有较大的相关性。通过回归分析得到基础设施、尊严、自主性、选择、及时关注、保密性、交流对疗养员满意度均有一定的影响,偏回归系数均为正值,因此这些项目得分越高,疗养员满意度水平也越高;从标准偏回归系数看,基础设施和尊严对就诊满意度影响作用最大,其后依次分别为尊严、自主性、选择、及时关注、保密性、交流。二、疗养院人力资源现状评价高层次人才匮乏,学历与职称层次相对较低是当前疗养院医务人员的主要特征。总体而言,疗养院的培训力度不够,不同工作类型的医务人员接受培训的程度不同,其中医生接受培训程度较高,医务人员对培训有着较高的意愿,年龄、是否接受过培训、工作类型等是影响医务人员培训需求意愿的重要因素。管理人员需求评估发现:最近2年接受过培训的人为36.73%,还不足一半,而管理者的培训意愿却非常高,较愿意及以上占97.56%,其中很愿意培训的达70.73%。他们对领导工作方法和领导艺术、疗养院质量管理、疗养业务技术管理、心理学在疗养管理中应用、人力资源管理等有较高的需求。管理人员和医务人员的培训均存在一定问题。医务人员对目前的培训的效果评价不高,问题主要集中在缺乏实践、针对性不强、培训时间短、学非所用、重点不鲜明、培训内容偏陈旧、存在走过场现象等诸多方面的因素。管理人员培训的问题主要集中在培训机会太少、培训时间太短、形式化气氛太浓、缺乏实践、上级部门不够重视、重点不突出等方面。其中管理者还认为在培训中起关键作用的因素是理论与实际结合程度、授课教师水平、培训内容、被培训者意愿、培训形式、被培训者的重视程度、时间长短、培训频次等。目前疗养院工作人员最不满意的方面主要集中在奖金福利、收入报酬、工作条件、社会地位、工作风险和压力、能力的发挥和成就感方面。组织发展目标、工作环境、个人发展、培训、服务对象、直接管理、质量目标、协调沟通、评估与报酬是影响工作人员工作满意的重要因素。分别对不同工作类型的工作人员的工作满意度影响因素进行研究中发现医生有发展目标、工作评估与报酬、工作环境、个人发展、协调沟通、直接管理、质量目标、质量监控等8个因素,其中工作评估、工作环境、个人发展对医生的工作满意度影响作用较大。护理人员的因素有工作环境、工作评估与报酬、员工职责、在职培训、协调沟通、服务对象、质量监控、院领导等8个因素,其中工作评估与报酬和员工职责两项对其工作满意度影响作用较大。管理人员的工作满意度的主要因素有个人发展、协调沟通、质量目标、质量控制、院领导等5个因素,以协调沟通和个人发展对其工作满意度影响作用较大。疗养院工作人员的稳定性较低,经统计有45.53%的工作人员曾产生过离开疗养院的想法。多因素分析发现,年龄、职称、工作评估与报酬、工作环境、个人发展、协调沟通是影响工作稳定性的重要因素,且随着年龄的增加,工作心态的稳定性增加,年青医务人员工作心态的稳定性较差。职称则以高职称者稳定性好。在这几个因素中,从标准偏回归系数的值来看,以工作环境和个人发展对工作人员稳定性影响作用较大。三、疗养院运行现状评估运用DEA法对全军16所疗养院的效率进行分析。整体分析,在所有疗养院中,达到总体有效的疗养院比例为31.25%,绝大多数疗养院不能达到总体有效,说明在投入、产出方面有过大或不足情况。在整个评价中最小得分为0.2,与总体有效值的极差为0.8。说明整个疗养院的总体有效性不高,而且疗养院间的效率差异较大。案例分析表明:在对疗养院效率分析的基础上,选取在2004年联勤体制改革中既有疗养院和医院合编,又有疗养院和疗养院合编的南京军区杭州疗养院,利用TOPSIS法对其2005～2007年三年的综合效益进行评价。结果表明杭疗三年来综合效益逐年提高。分析其原因为该院自联勤后积极构建“疗治双向互动、疗疗双向互动、资源双向互动”的双向互动新模式,说明在联勤体制下,“多军兵种结合、疗治结合、疗疗结合、医医结合”的技术建设能够有效推进疗养院合编单位的建设发展。四、特勤疗养相关研究特勤疗养员对目前的疗养项目最满意的项目是景观疗养,有80.62%的人对景观疗养满意或非常满意;其次是体格检查和健康鉴定,满意或非常满意分别为75.84%和73.03%;治疗疾病、健康教育、文化娱乐活动这三项大约有一半左右的人满意或非常满意;满意较低的是体能训练和生理训练,这两项的满意或非常满意分别为32.02%和32.58%。特勤疗养员在进行疗养时希望解决的问题被提及最多的是休息娱乐,缓解疲劳;然后依次为游览自然景观和人文景观、提高对工作环境的适应能力、放松心情提高心理健康水平、学习新的保健知识和方法、体格检查、健康鉴定等,合理饮食,纠正不良饮食习惯被排在最后。特勤疗养人员认为改善疗养质量需注意的方面中改善疗养住房条件被放在第一位,其后依次为丰富景观游览活动内容、提高健康体检和疾病治疗的水平、改善常规医疗设备条件、改善特勤疗养伙食营养、改善体能、生理训练设施和条件、提高生活服务保障水平、添置特勤疗养专项设备、加强环境卫生管理、改进疗养服务流程、改进工作人员的服务态度、加强与特勤部队的协调沟通、加强特勤疗养行政安全管理和改善文化娱乐设施条件。疗养院在特勤方面目前存在的主要问题:一是学科基础薄弱。对特勤人员有关生理、心理、体能、营养等特殊疗养要求的研究不深入、不透彻,实施特勤疗养的许多做法仍然依托多年形成的经验习惯或借鉴普通疗养的技术规范,知识相对陈旧。二是管理机制粗放。主要表现在运行机制不够顺畅;规章制度不够健全;管理手段不够先进。三是设施设备落后。全军现有特勤疗养用房均未达到文件规定的人均面积要求,最低的仅10余平方米;特勤疗养生活、训练、活动用房等配套设施建设不够完善,在认识上有将特勤疗养用房等同于普通宾馆用房的误区,存在着特勤疗养人员与地方人员一同住宿、体检、就餐和训练的“四混”现象。四是服务理念单一。对特勤疗养人才的特点和成才规律研究不够,特勤疗养人才普遍缺乏,一些特勤疗养院直接从事特勤疗养的工作人员中没有具有硕士以上学历的,全军疗养院系统达到总部关于特勤疗养工作人员学历、培训和工作经历等基本素质规定要求的比例不足30%。五、疗养院可持续发展策略研究根据本次研究结果和相关文献资料,提出了疗养院发展的5个阶段,初创期、停滞期、建设发展期、联勤适应期、建设具有我军特色的疗养院期。认为目前军队疗养院正处于联勤适应期和建设有我军特色的疗养院的双重阶段。利用SWOT和情景分析的方法,对疗养院自身优势、劣势和机会、威胁进行了分析,识别影响目前疗养院发展的7个关键事件是:联勤后疗养院的管用模式、组织结构、管理方式、资源构成发生了变化;普通干部疗养存在疗养对象和疗养秩序混乱的普遍现象疗养院工作人员培训机制的建立与完善;“疗治结合”是我军疗养院发展的必然趋势和方向,联勤后疗养院与医院合编的最大特点是两种技术资源的合并,最大的难点是技术理念和方法手段的兼容;科学的绩效评估体系;特勤疗养既是军队疗养院的特殊任务又是最重要的卫勤保障任务之一;提高医务人员工作稳定性,减少人才流失。并构建未来发展的3种情景:乐观情景、无突变情景和悲观情景。从宏观和微观层面提出了疗养院可持续发展策略:策略一:宏观控制疗养对象并建立有效的疗养秩序控制机制策略二:强化职能意识,全面落实各项措施,努力提高卫勤保障能力;策略三:实现疗养院人才队伍建设的突破,包括不同人员的培训;策略四:突出学科建设,坚持内涵发展,努力形成疗养康复技术特色;策略五:完善疗养院预防、保健、治疗、康复功能,实现疗治结合和整体医护观的新突破;策略六:建立疗养院的内部有效运作机制,采取各种有效措施,发挥优势,利用外部机遇,提高竞争力。更多还原

【Abstract】 Recently, the revolution of great combined service in the whole military had been carried out broadly, and the military sanitarium which has remarkable change in manage mode, work strategy, develop space and range of service object began to run under the combined service system. New system injects vigor in the construction and development of the sanitarium, meanwhile bring valuably developed opportunity. With the development of the new system, however, some deep problem began to turn up, such as manage mode, mechanism, talent and the combination of therapy and cure that constrain the further development of sanitarium. In spite of some research on sanitarium, the evaluation of satisfaction of patient, training and requirement of training of workers and managers, worker’s satisfaction, and the combination of therapy and cure and the provide of recuperate for the special worker is still a weak and blank field, the entirely, integrate and systemic research on the develop strategy of sanitarium was fewer. Hence, it is very important to discuss and solve these deep problems, in order to promote the sanitarium to develop healthy and continuance.This paper on the ground of other reviews, aimed at the difficulty, hot spot, weakness and blankness, exerts the approach combined quantifying and qualifying to collect relative information and to analyze the develop statue and relative factor of the sanitarium, which define the develop character of the sanitarium, and promote the strategy of further development of the sanitarium.Study purposes Analyze the operation statue of sanitarium now, and find the relative factors whichconstrain the development of sanitarium. Systemic study the strategy of the development of sanitarium, and promote thestrategy of sustainable development.Study contentsEvaluation of satisfaction and reactivity of sanitariumManpower resource statue of sanitariumThe evaluation of the statue of the operation in sanitarium.Related study on the special worker’s requirement and offering. Study on the strategy of sustainable development of the sanitarium.Research objectPromote relative investigation to 16 military sanitariums.Research and analyze methodsBased on the collection of general register data, exert the approach combinedquantifying and qualifying to make complementary investigation, meanwhile takeuse of search tools to collect literature.Quantity investigation include: Satisfaction and reactivity of worker, workers’relative content of training, satisfaction for job, spot check on stability, evaluationinvestigation on the training requirement of manager and the statue of efficient andservice supply of the sanitariums.Quality investigation includes: talking with the leaders of the sanitarium individually,special group discuss of the worker of sanitarium and the relevant people etc.The analysis of information adopts the method which combined descriptive researchand analytic research. Main methods include descriptive analysis, multi-factoranalysis, TOPSIS, DEA analysis, SWOT analysis, scene analysis, quality analysis etc.The quality analysis adopts a series of special analysis steps to understand theinformation.Main result of researchThe five main parts result has been shown follow.1. The revolution of satisfaction and reactivity of sanitariumAbout 93.06% people is relatively satisfied or very satisfied with the sanitarium, according to the result of the evaluation on the satisfaction with the sanitarium, and the average score of general satisfaction is 4.40 which in the front of all the items, which indicates that the sanitarium having high satisfaction can be accepted by most workers. However, the subject scores of medical supplies and logistic support are under the average, and satisfaction scores are lower. Among the reactivity, the evaluation of dignity is well, 92.59% people thinks that well or very well; secrecy of the sanitarium has receive highly evaluation, and 85.19% people consider it well or very well; 87.04% people think communication is well or very well; 51.39% people think in time attention is well or very well; 65.86% people think the living condition is well or very well; 74.60% people think the condition of check room is well or very well; 51.22% people think the cleanness is well or very well; than the evaluation on facilities and living condition is not very well. Being influenced by the feature of the mission of recuperation, the item that whether the worker can choose sanitarium is compare low, and there are 26.86% people can choose sanitarium; on the general evaluation of choice, there are 49.07% people consider it well or very well; on the general evaluation of social support, there are 51.03% people consider it well or very well. According with the evaluation score of the 8 factors, we can conclude that indignity, independence, secrecy, communication, in time attention and facilities are evaluated highly, and the choice and social support are low.Based on the investigation of reactivity and general satisfaction respectively, we use statistic method to do further research on the relationship between general satisfaction and each item. Then through the regression analysis, we conclude that facility, indignity, independence, choice, in time attention, secrecy and communication have some influence on workers’ satisfaction, and the partial regression coefficient is positive, so the higher these items scored, the more satisfied these worker are; in term of standard partial regression coefficient, facility and indignity have the most influence on satisfaction, followed by the indignity, independence, choice, in time attention, secrecy and communication.2. Evaluation of the manpower statue of the sanitariumThe sanitarium is lack of elite, and most worker on the sanitarium have low study and post.In general, the training of the sanitarium is not enough, different kinds of worker receive different degree training. Doctor receive high degree training, the nurses are eager to be trained, and the age, whether have been trained and the kind of worker are the important factors that influence the requirement of the nurse.Requirement evaluation of the manager observe that 36.73% people has been trained in resent 2 year, which is not half of the total, however, the eager of management to be trained is higher than 97.56%, even the number of management who most please to be trained is up to 70.73%. They have highly eager to receive the training of lead method, art of leadership, quality management of the sanitarium, technique management of operation, application of psychology in the management and manpower management.There are some problem in the training of manager and nurse. The evaluation of nurse to the training effect is not very well, the main problems are lack of practice, low accuracy, training period comparative short, what has been learnt could not be used, emphasis not clearly, training content old, as well as other aspect. The training problems of manger are lack of chance to be trained, training period comparative short, lack of practice, the attention paid by supervise not enough and the emphasis not clear. And in the view of manager the key factors in the training are the degree of the combination of the theory and practice, the level of the teacher, training content, the will of trainer, training form, the time and the frequency.Now the most unsatisfaction aspect of the worker is mainly concentrated on the reward, bonus, work condition, social statue, job risk and pressure, exertion of power and the feeling of accomplishment. The purpose of the development of team, work condition, individual development, training, service object, and direct management, purpose of quality, communication, evaluation and reward are important factors that affect the satisfaction of the workers.The stability of the workers in the sanitarium is lower, 45.53% workers had the thought to leave the sanitarium. Multi-factor analysis obtained that age, post, evaluation and reward of the job, worker condition, individual development and communication are the important factors that influence the job stability, and increasing with the age, workers’ the attitude to the work became more stable. The younger workers’ attitude is not stable, and high-post workers’ attitude is more stable. According to the standard partial regression coefficient, among these factors, the work condition and individual development have influence on the stability of the workers.3. Evaluation on the operation of the sanitariumAnalyze to the efficiency of the military sanitarium by the method of DEA generally, among the 16 sanitariums, and31.25% sanitarium reach the generally effect, while most could not reach the target, which indicate that there are excessive and shortage situation in the aspect of input and output. In the general evaluation, the lowest score is 0.2, which lower than the target of general effect by 0.8, which indicate the low generally effect of sanitarium, in addition, the diversification of the efficient of the sanitariums is distinctly.The analysis of some case indicate: on the base of effective analysis, Hang Zhou sanitariums of Nan Jin military area is a unit of sanitarium-hospital, hospital-hospital was selected, taking use of TOPSIS to evaluate the Hang Zhou sanitarium generally, and the result indicate that the general benefit of hospital and sanitarium is increasing year by year in recent 3 year. And the building of combination of hospital and sanitarium and the practice of the mode of act mutually can improve the combined unit effectively. Analysis of the reasons can find that positively constructed new technology build mode of interactive between convalescing and treatment, convalescing and convalescing, resource and resource, and tried a useful attempt in technology build of combination of services and arms, convalescing and medical treatment under the study of joint logistics system, and progress the development of sanitarium combination units.4. The related study of special convalescingThe most satisfactory project of resting therapy is landscape resting therapy, 80.62 percent of nurses are satisfacted or extremely satisfacted; Then, medical examination and health appraisal, the percent of satisfaction is 75.84 and 73.03 respectively; Half of the nurses are satisfied with disease therapy, health education and recreational activities; The satisfactory rate of physical ability training and physiologic training are low, 32.02% and 32.5% respectively.Nurses in resting therapy want to solve many problems: first, is resting and relax themselves; then, visit natural and human landscape, improve the adaptability of work environment, have fine mood to raise mental health level, learn new conservancy knowledge and methods, medical examination and health appraisal ect. The last one is reasonable food and drink, correcting unhealthy eating habit.Nurses consider that in order to improve quality of resting therapy, many aspects need to be pay close attention: first one, improving housing condition, then, colorful landscape tourist, improve the level of health examination and disease therapy, amendment routine medical treatment facility, increase nourishment, amendment facility and conditions of physical ability and physiologic training, upgrade the service flow sheet, improve staffs attitude, enhance communication with the armed forces, emphasis administrative security and improve the condition of entertainment facilities. The main problem of convalescent home is lack of professional foundations, can’t achieve the requirement of physiological, psychological, physical ability and nourishment of nurses; then, backward of expertise: most therapy is just according to the experience or common therapy technological specification. Another one, extensive administration system: operating mechanisms are not smooth enough; regulations are not well established; management instruments are less advanced. Lagging facilities. Now, therapy housing can’t reach the files requestment of areas per person, the lowest is just more than 10 m~2 ;the house of living, training and activity isn’t consummate, there’s miscampus that considering the therapy house equate to the normal guesthouse, and there’s phenomenon that special convalescing agents and local people Lodge ,health examination repast and training together. Simple servise concept. There’s not enough study of rules and feature about special convalescing talent, and lack of special convalescing talent is normal, some therapy house has none master directly dealing with therapy works. The percent of therapy system of armed forces which reach the requirement about staff’s educational background training and working experience is no more than30%.5. Research on the sustainable development of the sanitariumAccording to the result and relative information, 5 phases of the development of the sanitarium have been advanced, beginning phase, stasis phase, development phase, adaptation phase and set up the feature of our military sanitarium phase. It can be think that military sanitarium is in the double phases of adaptation phase and set up the feature of our military sanitarium phase now.Take use of the method of SWOT and analysis the situation, and analysis the own advantage and shortage of the sanitarium, and the opportunity and menace ,the seven key incidents that influence the development of the sanitarium are the change of management and use modes, organization structure, manage mode and resource composition,the universal phenomenon of complications in resting therapy object and order of common cadres, construction and perfect of the training mechanism of the workers, the combination of therapy and cure is the necessity trend and opposition of our army, the biggest characteristic is the combination of the two technique resources, and the most difficulty is the tolerance of the theory and means; rational evaluation system to the achievement and effect; special recuperation is not only the outstanding mission but also one task of the guarantee of medical; improve the stability of the workers to reduce the flow-out of elites. And construct 3 situations: situation of optimism, non-mutation situation and pessimism situation.Advance the sustainable development strategy of the sanitarium from the aspect of macroscopic and microcosmic:Strategy 1: regularizing the system of issuing of convalescing cortication, effective control of convalescing objective and order.;Strategy 2: strengthening the function consciousness, entirely fulfill each measure; increase the ability of hygienic guarantee;Strategy 3: realizing the increasing of the workers of the sanitarium, including the training of different staff;Strategy 4: extruding the subject construction, persist in connotation development, form the characteristics of convalescing and healing technologyStrategy 5: perfecting the function of sanitarium of prevention, health care, treatment and healing, realizing the new breaking of the combination of the cure and therapy and whole concept of medical and nurse;Strategy 6: establishing the inner effective mechanism of the sanitarium, adopting all effect measure, exerting the advantage, taking use of outer opportunity, advance the ability of complete.更多还原