【作者】 陈璞；

【导师】 陶红兵；

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

【摘要】 研究目标本研究在文献研究的基础上,比较我国双向转诊模式,选择两个具有代表性的双向转诊模式深入研究监管现状,探索双向转诊监管的影响因素,建立适合我国实际情况的双向转诊监督管理机制、界定监督主体及责任、监督内容和手段以及相应的激励约束措施,以促进不同模式下双向转诊管理的科学化和制度化,保证大中型医院和社区卫生服务机构之间双向转诊的顺利进行,促进病人的合理分流和医疗资源的有效利用。研究方法1.文献研究法查阅关于政府职责、医疗卫生服务、社区卫生服务等书籍和专业杂志期刊、论文集以及网上检索相关文献资料,收集国内外社区卫生服务机构与医院双向转诊监管有关论著和论文。关于社区卫生服务和双向转诊的各类文件资料。2.现场调查法现场调查南京市,无锡市,武汉市硚口区、青山区,深圳市宝安区、福田区等城市的医院和社区卫生服务机构的双向转诊模式和监管现状。采用分层随机抽样法对深圳、武汉市20个社区卫生服务机构的部分医、护、管理人员共109人进行问卷调查、对武汉市就诊患者和社区居民144人进行问卷调查,收集相关数据资料,通过epidata录入后应用spss12.0进行统计分析。3.关键知情人访谈法就双向转诊监管的现状,监管过程中存在的问题等内容对双向转诊密切相关管理人员、医务工作人员54名进行了访谈。其中天津市河东区卫生局分管副局长,分工合作项目办公室主任,试点医院和社区卫生服务机构管理人员共12人,广东省深圳市卫生局相关人员、宝安区、福田区四家医疗机构分管副院长、社康科主任、医务科主任和举办的社区健康服务中心主任共32人,湖北省武汉市硚口区卫生局、硚口区、汉阳区、青山区等地2家医院,5家社区卫生服务机构负责人共10人。对访谈结果进行归纳总结。4.专题小组讨论分别在武汉市,深圳市,厦门市,天津市召开了4次专题小组讨论会,每次组织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管理人员8-10人,对初步建立的监管指标、监管手段和监管内容的可行性进行讨论。5.统计分析方法应用描述性统计分析方法分析双向转诊的监管现状,监管的内容、手段、存在的问题等,应用卡方检验比较不同社会学特征人群双向转诊的知晓率情况,应用logistic回归分析方法探讨双向转诊监管的影响因素,应用对应分析方法分析影响患者转诊的因素。结果1.双向转诊模式和监管特点通过各地的双向转诊相关文件,结合文献资料,调查访谈结果,归纳出目前我国的双向转诊模式主要分为以下几种:政府主导模式下的双向转诊,管办分离模式下的双向转诊,院办院管模式下的双向转诊,民营社区卫生服务机构与医院互动模式下的双向转诊,不同模式下的双向转诊具有缺乏监管依据和激励约束等措施的共同监管特点。2.双向转诊的实施现状社区卫生服务机构的功能尚未充分发挥,主要体现在社区就诊比例低和上转容易下转难。通过对卫生部统计资料的二次分析发现,2007和2008年我国社区卫生服务中心(包括站)诊疗人次数仅占全国总诊疗人次分别为6.8%, 7.3%。本次调查结果显示无锡南长区月均上转人数是下转人数的7.78倍,天津河东区月均上转人数是下转人数的6.14倍。3.双向转诊的监管现状双向转诊工作易纳入到社区卫生服务机构的整体考核中,但是所占总分比例不高,其中武汉占考核总分的15%,深圳占考核总分的10%。监管效果欠佳,调查反映只有22%的工作人员认为监管效果好。4.双向转诊监管的影响因素对监管的影响因素进行问卷调查和访谈,结合logistic回归分析结果。表明双向转诊监管的影响因素主要有以下几个方面:监管的主体单一,受人为因素影响大(依次是社区卫生服务机构工作人员,上级医生,患者和家属),监管的依据缺乏,监管的手段有限,激励和约束机制不完善。5.双向转诊监管机制的构建在定量资料和定性资料研究的基础上,结合临床路径的管理方法构建双向转诊的监管机制。明确监管的主体,包括卫生行政部门,医保部门,第三方监管机构和社区患者或居民。制定监管的指标,对医院监管的指标包括住院日期和住院费用,下转符合率,对社区卫生服务机构的监管指标包括检查治疗情况,健康管理情况和上转符合率。完善监管的手段,包括住院日期控制图,住院费用控制图,现场考察,居民满意度调查和抽查病历等。另外要建立监管的信息系统和监管结果的反馈机制。讨论和建议1.加强双向转诊政策和法规引导有条件的地区制定城镇居民基本医疗保险、外来劳务工医疗保险的社区首诊政策,同时建立健全医疗救助的特困居民的社区首诊制。2.强化监管主体的监督作用培养社区居民和患者监督的主体意识。要多渠道加大双向转诊的宣传力度,营造社区居民和患者主动参与的良好氛围。发挥第三方的监管作用。其一是医保部门的监管作用。根据医院和社区卫生服务机构转诊的比例,转诊的符合率,转诊病种的平均住院时间和住院费用进行监管,其二是成立社区卫生服务工作管理中心,作为一个集双向转诊管理、卫生监督、防保指导、培训和公共卫生服务管理一体化的管理服务机构。3.畅通公众和第三方机构监管的渠道一种是通过各种信访组织的表达渠道,通过建立民主监管组织,向行政部门提供建议和反映问题,社区居民和患者可以通过上访、写信、投诉等多种方式进行监管。另一种是公开发表舆论的渠道,常见的渠道包括通过网上论坛,电视报纸等媒体披露。4.建立基于临床路径的双向转诊监管模式包括加快双向转诊临床路径的开发,不断改进双向转诊的管理路径。5.推进监管的制度化进程将城市医院和社区卫生服务机构的考核作为一种监管的制度,并且在从事监管的过程中遵循这些程序和规则。更多还原

【Abstract】 Objective :The study is based on the literature research , comparison of two-way referral patterns, choose two representative cities,in-depth study on the status quo of supervision .Take hypertension clinical pathway of two-way referral as an example, to explore the factors which impact supervision. Establish supervision and management mechanism of two-way referral according to China’s actual situation. Defining and monitoring the main department,content and means and the incentive measures of supervision, in order to promote scientific and systematic management of two-way referral, to keep two-way referral between hospitals and community health service institution running well ,to promote patients use medical resources rational and effective .Methods:1. Literature researchReading professional books and magazines, papers and online information about Responsibilities of government, medical and health services, community health services ,and different types of documents about community health services and two-way referral.2. Local InvestigationMaking research in the hospital and community health service institutions in Nanjing, Wuxi, Qiaokou District, Qingshan District in Wuhan. Bao’an District,Futian District in Shenzhen, ect, about pattern and supervision of the status quo of two-way referral; Systematic sampling method used, Having interviews with 109 staff in the City Community Health Service institution.in Shenzhen and Wuhan, to collect data on 144 medical patients and community resident by questionnaire survey. Data were entried by Epidata and statistical analyzed by spss12.0.3. Key insider interviewInterviews with 54 managers, medical staff with regard to the status quo of two-way referral monitoring, problems of the supervision. Including a total of 12 people in Hedong District in Tianjin( one in charge of the Deputy Secretary for Health, a division of labor, director of the office project, pilot hospitals and community health service managers),32 people in Baoan District or Futian District in Shenzhen (Health Department staff, the hospital vice president in charge of community health service institution, Medical Services Director, Director of the Center for Community Health Services ) .10 people in Wuhan(Hospital leadership and the leadership of community health services)4. The special group discussionTo discuss on the supervision mechanism of two-way referral about the difficulties and problems of the subject and the object、the content and means four times in Wuhan , Shenzhen, Xiamen and Tianjin. At least invited 8 to10 experts each time.5. Statistical AnalysisDescriptive of supervision status, explore the impact of supervision factors by logistic regression analysis. Find patients factors by correspondence analysis method.Results:1. Two-way referral patternsAt present, there are four two-way referral pattern in China : pattern of Government-led , pattern of separating between steering and rowing, pattern of operation and management by hospitals, pattern of interaction between Private community health service institutions and hospitals 2. The status of two-way referralLow proportion of the community clinic, the number of medical clinics accounted for the country’s total passenger trips by 6.8%, 7.3% in China’s community health service centers (including the station)in 2007 and 2008.patients are easily be transferred to the hospital but difficult transferred to the community. there are person transferred to the hospital to person transferred to community is 7.78times in south long zone of Wuxi, there are person transferred to the hospital to person transferred to community is 6.14times in south long zone of Wuxi Hedong District of Tianjin each month.3. The supervision status of the two-way referralSome cities have taken two-way work into the overall assessment, but the total percentage is not high, which is account for 10% of total in Wuhan and 20% in Shenzhen, ineffective supervision. only 22% of staff believe that effective regulation.4. The impact factors of the two-way referral supervisionThe impact factors of the two-way referral supervision including supervision of the main body of a single, by the influence of human factors (followed by community health service agency staff, higher-level doctors, patients and their families), lack the basis for supervision, with limited means of supervision, incentives and constraints imperfect mechanism.5. To build a supervision mechanism on two-way referralCombined with the management of clinical pathways to build supervision mechanism of two-way referral. The main body of supervision including health departments, health insurance departments, third-party supervision bodies and community-based patients or residents. Supervision indicators of the hospital, including inpatient hospitalization dates and costs, in line with the rate of transfer of community health services, including examination and treatment monitoring indicators, the health management and in line with the rate of turn. Means of supervision the date of control charts, including inpatient, hospital cost control plan, site visits, the residents satisfaction surveys and spot checks of medical records and so on. Improve two-way referral system supervision information. The results of the establishment of supervision feedback mechanisms, including written communication, oral communication, network communication and other forms of communication and the reward and punishment mechanism.Discussions and recommendations :1. To strengthen two-way referral guide policies and regulations. develop the first policy of the community based on the basic medical insurance for urban residents and foreign workers medical insurance services and at the same time establish and improve medical aid to poor residents of the first policy of the community.2. To strengthen the supervisory role of the main regulatory. Training the main sense of supervision of Community residents and patients. Increase two-way referral of publicity by multi-channel, Create a good atmosphere for residents and patients in community to participation.Play the role of monitoring by Third-party. One is supervision of the health insurance sector. According to the Hospital and community health services referral ratio, in line with the rate of referral, referral of diseases, the average length of stay and hospital costs of regulation. The other is to establish a community health service management center, as a set two-way referral management, health surveillance, preventive guidance, training and integration of public health services management services.3. Unimpeded public and third-party channels to supervision. One is the organized expression of channels, the other is the public expression of the channels of public opinion.4. The development of two-way referral clinical pathway management. Including two-way referral clinical pathway to accelerate the development of the patients in the clinics of the variation process.5. The protection of the regulatory examination process. Urban hospitals and community health services assessment as a regulatory system, and engaged in the process of monitoring compliance with those procedures and rules.更多还原