【作者】 张明新；

【导师】 方鹏骞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2009， 博士

【摘要】 近年来我国各级政府不断加强城市基层卫生服务体系建设，目标是近3年内基本实现城市社区卫生服务的全面覆盖，社区卫生服务体系将在城市居民的健康保障中发挥越来越重要的作用，为了达到发挥社区卫生服务机构的功能的目的，迅速提高社区卫生服务机构的服务能力将是我们面临的最大障碍之一。为了提高社区卫生服务机构的服务能力，卫生部于2006年6月下发了《关于公立医院支援社区卫生服务工作的意见》，要求各地积极探索建立医院与社区卫生服务机构定点协分工作关系和畅通的的双向转诊信息沟通机制。中共中央、国务院《关于深化医药卫生体制改革的意见》中也提出建立城市医院与社区卫生服务机构的分工协作机制。然而，我国医院和社区卫生服务机构的分工合作的现状如何?影响双向转诊的关键环节有哪些?双向转诊的运行机制如何构建?不同分工合作模式下双向转诊的改进策略如何?等等，成为社区卫生服务机构与医院双向转诊运行管理急需研究和解决的重要问题。本研究运用利益相关者理论、医疗服务需求行为理论、激励理论等对双向转诊运行管理进行了理论分析，提出基于利益相关者理论需要建立我国医院与社区卫生服务机构的双向转诊中不同利益者的相关卫生政策、医疗保障制度以及相应的管理策略。基于卫生医疗需求行为理论提出需要探索社区居民的人口学特征与居民医疗行为的相关性，以促进双向转诊的顺利开展。基于激励理论提出建立双向转诊的激励约束机制。在文献资料和二手资料分析的基础上，在对代表性城市双向转诊模式进行了现状调研，比较了各种模式的优势及存在的问题，探讨双向转诊运行管理中的各种影响因素并找出关键因素，并提出双向转诊运行的相关政策、管理策略与激励和约束机制，以构建适合我国国情的社区卫生服务机构与医院双向转诊运行的管理模式，为实现病人的合理分流，促进社区卫生服务机构和医院之间有效地开展的双向转诊，为有关卫生行政部门提供决策依据。资料来源与方法资料来源：收集国内外相关文献和不同地区的政府文件和相关二手资料，对社区卫生服务机构与医院合作模式的现状和各自的利弊进行比较分析。同时采用定性深度访谈和定量调查相结合的方法，对开展社区卫生服务机构与医院双向转诊工作较好的北京、天津、上海、南京、武汉、深圳等地区进行典型案例分析。同时邀请了相关领域的专家、卫生部门行政人员以及社区卫生服务机构和医院的相关工作人员进行专题小组讨论和个人深入访谈，分析各个地区社区卫生服务机构与医院之间双向转诊的现状与利弊。同时对样本地区的不同医院与社区卫生服务机构的分工合作模式的医保支付方式、患者就医意愿、社区卫生服务机构向上级医疗机构转诊的人次数、从医院转回社区卫生服务机构的人次数，转诊的疾病构成等进行了现场调查。研究方法1、文献回顾与情报分析广泛查阅国内外双向转诊的有关专著、学术论文、专业杂志期刊以及网上检索相关文献资料，收集国内外双向转诊现状和影响因素、相关制度和运行机制的相关资料，并应用meta分析方法对收集来的各类文献资料中的主要观点进行归纳总结，作为研究方案的依据。2、个人深入访谈通过对深圳、武汉和天津市卫生行政管理人员、社区卫生服务机构工作人员、社区卫生领域的相关专家共26人的半结构访谈，分析各个地区社区卫生服务机构与医院之间双向转诊的现状与利弊，为确定适合我国实际的社区卫生服务机构与医院双向转诊运行的管理模式提供参考。3、问卷调查法对双向转诊功能发挥较好的南京市、北京市、上海市、天津市、深圳市、武汉市等六个城市，根据社区卫生机构的管理模式和双向转诊机制，在每个城市选取3家医院、9-12家社区卫生服务机构作为研究现场，随机抽取社区卫生服务机构就诊的患者288名进行调查。4、专题小组讨论通过卫生行政管理部门有关人员、医保部门负责人、医院有关人员以及社区卫生服务机构人员的专题小组讨论，了解社区卫生服务机构与医院之间双向转诊的影响因素，确定双向转诊存在的问题，探讨行之有效的解决办法。5、典型案例分析通过对不同模式下社区卫生服务机构与医院双向转诊的典型案例分析，结合文献资料总结与个人深入访谈，对不同模式下医院和社区卫生服务机构双向转诊的利弊进行分析。6、资料分析处理方法6．1统计学分析方法：用描述性统计学分析方法对不同地区社区卫生服务机构与医院双向转诊人次数、转诊疾病构成进行分析。应用卡方检验分析在不同人口学特征人群就医行为与意愿的差异比较，应用logistic回归检验分析在不同人口学特征人群就医行为与意愿的影响因素。6．2利益相关者分析：将政府、居民、医院、社区卫生服务机构以及医疗保险机构定义为不同的利益相关者，进行利益相关集团分析，运用归纳演绎等方法，探索其行为特征的相互作用，研究社区卫生服务机构与医院双向转诊的动力和阻力。研究结果与分析1、社区卫生服务机构与医院双向转诊相关理论研究在双向转诊过程中涉及的主要利益相关者包括：政府、医院、社区卫生服务机构、患者、医疗保险机构等。基于利益相关者理论需要建立我国医院与社区卫生服务机构的双向转诊中各方利益相关者的利益冲突的协调机制，在保障患者根本利益的基础上，兼顾医院、社区卫生机构和医疗保险机构的具体利益，充分考虑社会各方面的承受能力，研究协调不同利益者的相关卫生政策、医疗保障制度以及相应的管理策略。基于卫生医疗需求行为理论研究分析表明患者的等候时间、就医距离、患者年龄、受教育程度、性别、就医成本、疾病严重程度等在特定的地区对个人卫生医疗需求行为的影响非常显著。对社区居民的人口学特征与双向转诊意愿非常重要。医疗服务供给行为分析理论表明医疗服务的需求与供给同样受到医疗价格机制的影响，人们对医疗服务的合理需求只能在消费者的边际收益等于他付出的边际成本时才能实现。激励理论分析提示双向转诊管理的激励和约束机制建立时，应充分考虑管理对象的需求，从而采取有效的激励措施。2、国内外双向转诊模式现状以及不同模式的利弊分析澳大利亚的医院和社区卫生服务机构建立一个更全面的双向转诊制度，英国实施该系统的全科医生的服务，新加坡政府制定了严格的病人传输系统，美国主要依赖关于医疗保险制度中的作用。国内社区卫生服务机构与医院双向转诊模式主要包括以南京、北京、天津市为代表的协议合作模式、以深圳市、大庆市为代表的院办院管模式、以武汉市、唐山为代表的“托管”模式和以利益为导向的松散型模式等4种模式。不同合作模式存在不同的利弊，协议合作模式、院办院管模式和托管模式适合不同地区探索，利益为导向的松散式模式，由于医院和社区卫生服务机构双方以短期经济利益为导向，缺乏分工合作的长期目标和合作意识，不值得推荐模式。3、双向转诊的关键环节与影响因素影响双向转诊的关键因素包括：公众对社区卫生服务不信任，对大医院存在惯性心理依赖；上转容易下转难的现象比较普遍；举办医院之间、社区卫生机构之间发展水平不一，很难执行统一的制度和标准；缺乏有效的激励约束措施和操作性强的奖惩方案，导致医务人员转诊意识淡薄。4．社区卫生服务机构与医院双向转诊运行管理模式构建通过分析研究发现，很多城市根据当地的实际进行了大胆的探索，摸索了不同的社区卫生服务机构和医院的双向转诊模式，但每种模式各有利弊，我们在对不同模式进行比较分析和关键影响因素的基础上，提出了双向转诊运行管理策略。包括双向转诊的基本原则、协调机构、相关部门职责与工作内容、双向转诊的参考指征、转诊协议和优化转诊流程、双向转诊的信息沟通和设备共享机制、评价和激励约束机制5、双向转诊运行管理的相关政策现状与对策分析要构建双向转诊的可持续发展模式，必须有必要的配套政策保障，目前，存在政策缺位和错位问题，有的过时，所以，对这些政策都需尽快加以制定和完善。我们在对不同模式进行比较分析的基础上，对形成一种可持续发展的双向转诊模式的相关政策进行了归纳总结，提出在保障双向转诊的基本条件前提下，明确各部门职责，加强多部门合作，完善医保政策、居民引导政策、财政补偿政策和人才培养政策，同时制定相关的法律法规，并通过政府部门或者第三方强有力的监管，使各部门能较好的履行各自的职责，通过配套各项政策的落实，使双向转诊的各项工作有效开展。讨论与建议根据我国医院和社区卫生服务机构双向转诊现状、关键问题以及政策分析，指出在一定时期内我国医院和社区卫生服务机构双向转诊的不同模式需要同时存在，目前大部分城市以医院与社区卫生服务机构协议合作模式为主，同时院办院管模式和“托管”模式也具有一定的代表意义，以利益为导向的松散式模式中医院和社区卫生服务机构过于注重短期利益，不利于双向转诊持续开展和相关机构的功能实现，根据目前的实际针对前三种模式的改进提出以下建议。1、协议合作模式政府的职能实现是否到位是双向转诊顺利开展的关键。医院与社区卫生服务机构的双向转诊，必须有政府强有力的监管和指导，坚持政府举办的社区卫生服务的公益性质，使医院与社区卫生服务机构双向转诊收到积极的效果。同时还要制定统一的转诊标准，建立利益引导机制，实行以奖代补政策，促进医院与社区卫生服务机构的合作。2、院办院管模式成立人权和财权相对独立的社区卫生服务管理中心，负责对双向转诊中各方职责的履行情况进行有效监管，引入医疗保险定点机构的准入机制和退出机制。转变院长观念，制定双向转诊激励约束机制，在促进上转的同时，提高下转人次数。3、“托管”模式理顺大医院与社区卫生服务中心之间的利益关系，将大医院与社区卫生中心的“竞争关系”变为“互补关系”，社区卫生服务机构的管理者要转变观念，积极主动参与与医院的双向转诊。同时加强大医院委派人员的全科医学培训和社区卫生机构管理的培训，避免“托管”后社区卫生服务机构的“专科化服务”倾向。更多还原

【Abstract】 In recent years, governments at all levels of our country strengthen theconstruction of urban grass-roots health service system continuously.Their goal was torealize the comprehensive cover of community health service of city in threeyears .The community health service system will play more and more important roleon the aspect of the health protection for the urban residents .To display the functionof the community health services institutions, it will become the major obstacles toenhance the capacity of the community health services institutions rapidly.In order toenhance the capacity of the community health services institutions, ministry of Healthpromulgate the Document of The Proposal for Regarding Public Hospitals Supportthe Community Health Services Work,it demands Local Government to explore theCollaborative relationship between the community health services institutions andhospital and effective information communication channel for two-way referral. TheCPC central committee and state council promulgated the Document of The advice fordeepen the reform on the medical and health ,it also pointed out that the mechanismof division and cooperation for the community health services institutions and urbanhospital should be established.However, what about the present situation of thedivision and cooperation between the community health services institutions and hospital?Which links are the key factors to impact the two-way referral?How toestablish the operations mechanism of two-way referral?What is the improvementstrategy for the different model of two-way Referral? Etc.The problems above arebecome the most important ones on the mangagement of two-way referral operationswhich are demand to research and solve.This research apply stakeholder theory and the theory of demand for medicalservices to analysis the operations and management of two-way referral. Based on thestakeholder theory ,it pointed out that it should be established the related health policy,the medical security system and the corresponding management strategy for differentstakeholder in the process of two-way referral. Based on the theory of demand formedical services, it pointed out that to explore the relevance between the demographiccharacteristics and the medical behavior of the community residents. Based onreviewing the literature and analyzing the second-hand information,we investigatedthe present situation of the different two-way referral model in representative cities;compared the advantages and problems of various models; discussed the variousinfluencing factors in the management of two-way referral and found out the essentialones,and at the same time establish the related policy, management strategy and theincentive and restraint mechanisms,in order to construct the management model oftwo-way referral operation which fits the condition of our country. To realize thepatients’ reasonable Fan Lau and promote the two-way referral to carry out effective,and offer the basis for decision making to the related departments.Data Source and Research MethodsData SourceCollecting the information in and abroad about the effect factors, the governmentdocuments of different regions and related second-hand information,to analysis thepresent situation and the pros and cons.The research methods inelude qualitative andquantitative study, making research in the hospital and community health service institutions in Beijing, Tianjin, Shanghai, Nanjing, Wuhan, Shenzhen, ect, abouttwo-way referral; invite the health management scholars, the experts of communityheath, the health officials of the executive branch, community health service staff andclinical professional experts to discuss on the pros and cons of various models oftwo-way referral.At the same time,we have a site investigation for different models’medicare payment, the wishes for medical treatment, the number of referred fromcommunity health service institutions to hospital and the number of referred fromhospital to community health service institutions.Research Methods1、Review the literature and analyze the informationReading widely the famous works, the learning discourse, the major magazineand the index literature information on the Internet in and abroad the country.Collecting the information in and abroad about the effect factors, the system and therunning system of the dual referral. Concluding the main points of them. They are allthe basis of the research. Meanwhile collecting the information of the denizen medicaltreatment and willings, which provides the basis to the denizen medical treatment andlead patients to have a treatment.2、In-depth iterviewInterviewing 26 pepole including the health administrators, community healthservice staff and clinical professional experts, Analysis of the the quo status and prosand cons of the two-way referral between community health services and hospitals invarious areas. In order to provide reference for determining two-way referralmanagement models between community health service institutions and hospitals thatsuitable for the reality of our country.3、Questionnaire survey methodMaking research in citis run two-way referral better , including Nanjing,Beijing, Tianjin, Shenzhen, Wuhan, ect.Acorrding to manegement model and Two-way referral mechanism.Choosing 3 hospital and 9 to 12 Community healthservices to survey, surveying 288 patients treatment in different models communityhealth random.4、Focus group discussionsThrough focus group discussions relating to the relevant personnel of healthadministrative departments, hospital personnel and community health services staff ,to find the influencing factors of Two-way referral between community healthservice institutions and hospitals. Definituding the problem of the two-way referral ,exploring effective solutions.5、Typical case analysisAnalyze typical case and he advantages and disadvantages of two-way referralbetween community health services and hospital of different models, combined withthe literature summarized and in-depth interviews with individuals.6、Data analysis approach6.1 Statistical analysis method: using descriptive statistical analysis of the number oftwo-way referral , referral constitutes of disease between community health servicesand hospital in areas . Application of chi-square test analysis of the differences inbehavior and the will by comparing demographic characteristics in different treatmentgroup, application of logistic regression to analysis of influencing factors in differentpopulation groups6.2 Analysis of stakeholders: take the analysis on the related benefit group by definingthe government, residents,hospitals, community health service institutions and healthinsurance institutions into different stakeholders. Study the dynamic and resistance ofthe dual referral by the way of summarized interpretation to explore the interaction ofthe behavior character.The results and analysis1、Theoretical research on two-way referral between community health service institutions and hospitalStakeholders in two-way referral process including: hospitals, community healthservices, patients, health insurance institutions. Theory based on the needs ofstakeholders need to establish the two-way referral coordination mechanisms ofconflict of benefit between China’s hospitals and community health services, on thebasis of protecting the fundamental benefit of patients, At the same time taking intoaccount the benefit of community health institutions and health insurance agency,Giving full consideration to all aspects of community affordability. Research healthpolicy, medical security system and the corresponding management strategy tocoordination of different stakeholders.Behavior based on the theory of demand for health care study found that thewaiting time for patients to seek medical treatment, distance from the patient’s age,educational level, gender, medical treatment costs, the severity of disease lead verysignificant impact on personal medical need in specific areas,and important for thepatients will of two-way referral.The supply behavior analysis theory of medical services showed that the demandfor medical services and supply was infected by the medical price mechanism,medical services can be achieved only when marginal income was equal to themarginal cost. Motivation theory analysis showed that we should give fullconsideration to the needs of managed objects in order to take effective incentiveswhen two-way referral management of the establishment of incentive and restraintmechanisms was established.2、Analyzing status of the domestic two-way referral models, as well as the pros andcons of different modelsAbroad: Australia hospitals and community health institutions to establish a morecomprehensive two-way referral system, the United Kingdom to implement thesystem of general practitioner services, the Singapore government has formulated strict level of the patient transfer system, the United States to rely largely on the healthinsurance system in the role of norms.Domestic: There are four type two-way referral models between communityhealth service institutions and hospitals in China, including the model of cooperationagreement , On behalf of the City is Nanjing, Beijing, Tianjin. And model ofoperation and management by hospitals, on behalf of the City is Shenzhen、Daqing.The model of delegated administration, on behalf of the city is Wuhan, Tangshan. Themodel of Oriented to the interests.Different co-operation models consist of advantages anddisadvantages .Agreement co-operation model , model of operation andmanagement by hospitals and trust model are suitable for different regions toexplore ,however, Loose model oriented -interest does not deserve recommendationdue to short of Long-term goals and awareness.3、The key influential factors related to two-way transfer treatment systemThe key influential factors of two-way referral include: Laws andRegulations ,hospitals ,CHS, medical insurance , the crowd sentiment.4、Establishment of two-way transfer treatment system among CHS and hospitalsAfter research & analysis ,we find that many cities have explored kinds oftwo-way transfer treatment systems on the basis of local conditions which compriseadvantages and disadvantages .On the condition that analyzed different models andkey influential factors ,we established the strategies to promote the operation oftwo-way transfer treatment systems.the strategies involve basic principles ,cooperating agency , functional responsibility ,indicators、agreement、process、mechanism of information communication、equipment sharing and performanceevaluation of two-way transfer treatment system.5、Supporting policy analysis of the operation of two-way transfer treatment systemsConstruct sustainable development model : After research & analysis ,we find that many cities have explored kinds of two-way transfer treatment systems on thebasis of local conditions which comprise advantages and disadvantages . Aftercomparative analysis of different models ,we summaried relative policies to push thedevelopment of two-way transfer treatment systems and outlined the strategies : todefine responsibilities ,to strengthen co-operation ,to improve the medical surancepolicies、financial compensation policies、personnel training policies , to developlaws and regulations , to strengthen the supervision by the governments orindependent party to promote the implement of the resposibilities and policies toobtain the good perfermance of two-way transfer treatment systems.Discussion and suggestionsAccording to the current situation and the key factors and policies analysis,different models of two-way transfer treatment systems will co-exist for a long time inour country.At present , agreement co-operation model is a main model betweenhospitals and CHS . At the same time , the model of hospital operation andadministration and the model of hospital trust have practical significance ,however,loose model oriented -interest which attaches more importance to short-term interestsis not conducive to the long-term development of two-way transfer treatment system.According to the actual conditions ,we raise special suggestions about the first threemodels.1、Agreement co-operation modelThe full realization of government functions is the key of the successfuldevelopment of two-way transfer treatment system which need effective supervisionand guidance of governments ,public interest of CHS.at the same time ,the standardsof two-way transfer treatment system should be designed and mechanism of thedistribution of benefits should be established.2、The model of hospital operation and administrationEstablish management center of CHS. The center is responsible for supervision of relative work,especially, pay great attention to supervision andassessment .Establish the mechanism of selection and removement CHS becominginsurance institutions.Design incentive and constraint policies .Change concepts ofhospital manangers to increase the number of patients being transferred to CHS fromhospitals.3、The trusting model between hospitals and CHSAdjust the interest relationship between hospitals and CHS, changing fromcompetitive relationship to co-operative relationship, the managers of CHS shouldchange concepts and take participate in two-way transfer treatment system.更多还原