【作者】 张松荣；

【导师】 孙振球； 刘小立；

【作者基本信息】 中南大学 ， 社会医学与卫生事业管理， 2010， 博士

【摘要】 研究背景：随着工业化、城镇化、人口老年化进程加快和生活方式的转变,人类疾病谱已发生了明显改变,我国居民心脑血管病、糖尿病、恶性肿瘤等慢性疾病患病率快速增长。根据《中华人民共和国第四次国家卫生服务调查主要结果》,2008年调查地区居民慢性病患病率为20.0%,比2003年增加4.9个百分点,推算全国慢性病总病例数达到2.6亿,过去十年年均新增近1000万例。其中,高血压病和糖尿病的病例数增加了2倍,心脏病和恶性肿瘤的病例数增加了近1倍；慢性病持续到两周内的病例在过去十年内由39%增加到了61%,慢性病死亡占总死亡比例从73.8%上升到80.9%。2008年深圳慢性传染病发病报告总数比2004年增加了127%；全市性病发病率为224.95/10万,远远高于53.87/10万的全国平均水平；全市高血压患病率约为13%,患病人数130万(按全市1000万人口),高血压、糖尿病等慢性病形势更加严重。这些慢性疾病不仅对患者造成身体伤害、心理创伤,严重影响了居民的生活质量,成为家庭和社会的沉重负担,也已成为危害居民健康的主要公共卫生问题。近年来,随着医疗卫生体制改革的不断深入,深圳市慢性病防治机构在防治机制、财政投入、工作绩效、服务质量等方面均有所改善,但整体水平还不足以应对快速增长的慢性病发病形势,难以满足居民日益增长的健康需求,各机构急需改善和提高服务能力与服务质量,以适应新形势的要求。研究目的：开展服务质量评价,不仅是各公共卫生机构提升服务能力、改善服务质量的重要手段,也是完善公共卫生体系建设、优化资源配置、提高公共卫生服务均等化、协助管理部门进行监督的有效方法。2009年《中共中央国务院关于深化医药卫生体制改革的意见》中也明确提出“加强公共卫生服务体系建设,完善公共卫生服务功能,提高运行效率、服务水平和服务质量”的要求。本研究的主要目的是：1.构建深圳市慢性病防治机构服务质量评价指标体系。2.构建深圳市慢性病防治机构服务质量综合评价模型。3.对深圳市慢性病防治机构的服务质量状况进行实证研究。研究方法：本研究运用公共卫生管理学科的有关方法,以深圳市慢性病防治机构职能和核心业务为基础,结合其现有条件和自身特点,采用定性研究和定量研究相结合的方法,围绕“完整性、代表性、科学性、有效性”等基本原则,建立服务质量的评价指标体系和综合评价模型。采用文献查阅、现场调研、专家访谈和小组讨论等方法建立指标体系初稿；通过对30多位公共卫生专家的2轮专家咨询进行指标筛选和权重估计,其中第一轮35位专家,第二轮31位专家,在专家年龄、专业、学历、职称、地域分布方面都进行了较好的组合；指标的评价标准来源于国家卫生部门相关业务规范；实证研究以深圳市6家区级慢性病防治机构为研究对象,采用问卷调查和现场评价相结合的方法；运用综合评分法、加权RSR法和加权TOPSIS法对实证结果进行分析比较；采用Epidata3.0建立数据库,使用SPSS15.0、SAS9.0等统计分析软件对所有数据进行统计分析。研究结果：本研究以Donabedian的卫生服务评价理论为基础,建立了以“基础、过程和服务结果”为主体的质量评价概念性框架,其中基础质量包括政策保障、制度保障和能力保障3个维度；过程质量包括监测网络、疾病监测、健康调查、行为干预、健康教育和工作督导等6个维度；服务结果包括健康促进状况、疾病防治效果和满意度等3个维度。指标体系共有3个一级指标、12个二级指标、80个三级指标,并在此基础上建立了以综合评分法为基础的综合评价模型。2轮专家咨询中,第一轮35位专家,第二轮31位专家,专家积极系数分别为88.6%和96.8%,说明专家合作程度很高；所有指标的专家判断系数、熟悉程度系数和权威程度系数均在在0.8以上,变异系数均在0.2以下；一、二、三级指标的专家协调系数分别为0.7613、0.7587和0.5661,在α=0.05的水平上均具有统计学意义；两轮专家咨询全部指标“重要性”均值分别为8.391和8.533,变异系数均在0.2以下,具有较好的集中度；3个一级指标的权重分别为0.198、0.408和0.394。实证研究发现,6家慢性病防治机构服务质量整体水平较好,其综合得分分别为913.9、880.7、849.5、804.4、762.9、698.9,从好到差的顺序是：H1、H2、H3、H4、H5、H6;本研究构建的综合评分模型与TOPSIS模型和RSR模型评价结果的相关系数分别为0.994和0.999(P<0.01),具有较好的一致性。研究结论：1.本研究率先构建了深圳市慢性病防治机构服务质量综合评价指标体系。指标体系涵盖了深圳市慢性病防治机构的基本职能和主要业务,数量精简,重点突出；指标权重分配合理,具有较好的科学性和可行性,是当前最为完整、系统的慢性病防治机构服务质量评价指标体系；2.本研究率先构建了基于综合评分法的综合评价模型。对每个三级指标提出了具体的标准和评分方法,制定了相应的操作量表,明确了评价要素、评分规则,提出了各评价对象的综合得分计算公式,具有较好的操作性。3.实证研究发现,深圳市慢性病防治机构服务质量整体水平较好。采用上、中、下3档分类标准,H1为上档,其余5个机构均为中档,没有属于下档的单位；6家区级慢性病防治机构服务质量从高到低的排序为H1、H2、H3、H4、H5、H6;本研究构建的综合评分模型与常用的TOPSIS模型和RSR模型的评价结果具有较高的一致性。更多还原

【Abstract】 Background:With the industrialization, urbanization and aging population, our lifestyle changes, and this leads to the obvious changes in human disease spectrum. Rapid growth of cerebrovascular disease, diabetes, cancer and other chronic diseases are also found in our residents. According to " Major findings of the fourth national health services survey in the People’s Republic of China ", residents surveyed suffering from chronic disease rose to 20.0%, increasing 4.9 percentage in comparison to that of 2003. Hence the estimation that cases of chronic diseases nationwide totals to 2.6 million, with the annual increase of 10 million over the past decade. Among them, cases of hypertension and diabetes increased by 2 times, heart disease and cancer by nearly 1-fold; chronic disease lasting two weeks increased from 39% to 61% in the past decade, and 80.9% died from chronic disease, while 10 years ago,73.8% died from those diseases. Chronic infectious diseases in Shenzhen in 2008 reported an increase of 127% than in 2004; 224.95 of 10 million citizens are found to be suffering from the chronic diseases, which is far higher than that of the national average (53.87/10 million); 13% citizens are suffering from hypertension, with victims of 1.3 million (according to the city’s 10 million population). It is worse with hypertension, diabetes and other chronic diseases. These chronic diseases not only cause physical injury, psychological trauma in the victims, and become the heavy burden of their families and the community, influencing their quality of life, but also become a major public health problem for their being great health hazard to residents.In recent years, with the health system reform in depth, Shenzhen agencies for preventing chronic diseases improved their service in disease prevention and control mechanisms, financial investment, job performance and service quality, though left a lot to be done in coping with the fast deterioration of the chronic disease outburst, in meeting resident’s growing needs for healthiness. Thus those agencies need breakthroughs in their service and self development.Objectives:To launch the Service Quality Evaluation in public health agencies, is not only an important means to enhance their serving capability, improve their serving quality, but also an effective method to perfect the public health system, to optimize the allocation of resources, to improve the equalization of public health services and to assist the supervision of the management. In 2009, "the CPC Central Committee State Council Views on Deepening the Reform of Medical and Health System" also clearly stated the requirements of "strengthening the public health service system, improving public health services, improving operating efficiency, service level and service quality". The purposes of this study are:1. Constructing Shenzhen Municipal Chronic Diseases Service Quality Evaluation Index System.2. Constructing Shenzhen Municipal Chronic Diseases Service Quality of Integrated Evaluation Model.3. Studying on service quality of Shenzhen chronic disease prevention and control institutions.Methods:Public health management approaches are applied in this study. Service Quality Evaluation Index System and Evaluation Model is established, based on the functions and core business of the chronic disease prevention and control institutions in Shenzhen City, combined with the existing conditions and its own characteristics, including the qualitative and quantitative research method, obeying the principles of "integrated, typical, scientific, and effective". Literature review, field research, expert interviews and group discussions were applied to establish the first draft index system; target screening and weight design are conducted among more than 30 public health experts consulted in two rounds, in which 35 experts in the first round and 31 experts in the second round. The age, profession, education, job title, geographic distribution of the experts gained consideration and a good combination. The criteria for the indicator evaluation derived from the national health departments’related business rules; 6 district-level chronic disease prevention and control institutions in Shenzhen are subject to the empirical study, who are investigated by the combination of questionnaire survey and field evaluation; the results of the empirical study are analyzed comparatively by using comprehensive score, weighted RSR method and the weighted TOPSIS method; A database is established by using Epidata3.0, and the data are analyzed by SPSS 15.0, SAS9.0 etc.Results:In this study, based on the Donabedian Theory of health services evaluation, a conceptual framework of quality assessment is established with "basis, process and service outcome" as its main part. The "basis" includes 3 dimensions of policy guarantee, system guarantee and the ability guarantee; the "Process" includes 6 dimensions of monitoring network, disease monitoring, health surveys, behavior intervention, health education and work supervision; the "service outcome" includes 3 dimensions of health promotion state, disease control efficacy and satisfaction. A comprehensive evaluation model is established on the basis of comprehensive scores received from the Index System which includes 3 level one indicators,12 level two indicators,80 level 3 indicators.In 2 rounds of expert consultation, including 35 experts in the first round and 31 in the second, positive coefficients were 88.6% and 96.8% respectively, indicating experts’high level of cooperation; all indicators’ expert judgments coefficient, familiarity coefficient and authority degree coefficient are above 0.8, with the variation coefficient of below 0.2; experts coordination coefficients in level one, level two, level three indicators were respectively 0.7613,0.7587 and 0.5661, statistically significant at the level ofα= 0.05. In 2 rounds of expert consultation, the mean "importance" of all the indicators are 8.391 and 8.533 separately, with the variation of below 0.2, showing good concentration; 3 level one indicators weights 0.198,0.408 and 0.394. It is found in the empirical study that the overall service levels of the 6 chronic disease prevention and control agencies are good, with the integrated score of 913.9,880.7,849.5, 804.4,762.9,698.9 respectively, and the order from best to worst is:H1, H2, H3, H4, H5, H6; the correlation coefficients of the 3 evaluation methods are 0.994 and 0.999 (P<0.01).Conclusions:1. It is the first in building quality evaluation index system of Shenzhen chronic disease prevention and control institutions. Concise and highlighting, the index system covers the basic functions of the chronic disease prevention and control institutions and their main business; with the reasonable target weight, being scientific and practical, it is currently the most complete and systematic service quality evaluation index system of chronic disease prevention and control agencies.2. It is the first in building evaluations of comprehensive scores based on a comprehensive evaluation model. Specific criteria and scoring methods are developed in indicators of 3 levels; operating scales for each indicator are developed, clarifying the evaluation factors and rating rules; the evaluation formula of integrated score received by the subjects are also proposed, hence a operative model.3. It is found in the empirical study that chronic disease prevention and control institutions in Shenzhen can provide good services overall and they can be classified into 3:upper, middle and lower. H1 belongs to the upper class, and the other five are middle, leaving no one to the lower class. According to their service quality, the six district-level chronic disease prevention and control institutions can be ordered from upper class to lower class as following:H1, H2, H3, H4, H5, H6; and 3 kinds of assessment methods were consistent.更多还原