【作者】 崔德行；

【导师】 冯占春；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2012， 博士

【摘要】 研究目的公立医院院长队伍的职业化建设与改革,能够推动公立医院改革向纵深方向发展。在激烈的医疗市场竞争中,公立医院院长管理能力高低、职业素养优劣等将直接影响到整个公立医院的发展与效益。国外发达国家的实践经验说明院长职业化的可行性,同时也为我国院长职业化改革提供经验借鉴。在我国,如何促使公立医院院长从“专家管理”向“管理专家”转变、走职业化发展之路被逐步提上日程。但院长职业化改革不是朝夕之举,改革过程面临诸多不确定因素,职业化改革在中国的可行性还需要进一步论证。本文选择公立医院院长职业化为研究对象,期望通过研究,完善其理论体系,深入分析改革中的宏观环境,挖掘可能导致改革阻滞的关键环节和因素,同时提出职业化院长的胜任力模型框架和逐步实现策略,构建符合我国国情的、满足职业化改革需要的、切实可行的公立医院院长职业化改革制度安排和支撑环境。研究方法整个研究中将理论分析(如规范分析、政策分析)与实证研究、定性分析和定量分析相结合思路贯穿始终。首先开展文献资料分析工作,吸收职业理论、社会角色期望理论、新制度经济学、治理理论等理论基础,对公立医院院长职业化改革的相关理论进行分析。设计研究方案,抽取19家公立医院的82名院长和595名中层管理者作为现场调查对象,并对政府、公立医院、卫生局、研究人员等关键知情人进行半结构化访谈,深度挖掘研究资料信息。现场收集的资料利用SPSS13.0进行数据录入,采取描述性分析、卡方检验、非参数检验、Logistic回归分析等定量统计分析方法,对研究中获取的访谈资料、政策文件、报告、灰色文献等资料进行定性分析。研究结果1.公立医院院长职业化的内涵界定公立医院院长职业化是过程与结果的结合。从过程而言,职业化改革意味着从职业观念、职业制度、职业环境、职业人队伍建设等各个角度赋予改革以推动力；从结果而言,职业化代表职业化院长作为一种独立的社会职业,得到法律承认,职业院长市场逐渐完善,实现了院长的价值取向职业化、素质职业化、配置市场化和职位的社会认同化。2.公立医院职业化院长的社会角色定位与角色管理设计职业化院长的社会角色是职业化院长在与公立医院、政府部门、其他社会组织、公众的互动关系中形成的,适应社会期望而存在的一种角色模式。角色定位应必须结合宏观、中观和微观角度,从政府与社会、医院与个人等多维度去定义、识别新角色期望的内涵。本研究分别提出政府部门、卫生市场和医院视角下职业化院长的角色定位。整个设计而言,职业化院长以经营管理为终身职业,遵循严格的市场准入机制和退出规则,通过与医院签订契约,以经营者的合法身份经营管理医院,凭借其拥有专业管理技能,实现医院经济效益和社会效益目标。在新型角色管理上,将医院院长职业作为一种独立职位进行管理,实现医院院长价值取向职业化,具有严格的职业准入规则,实行市场化配置方式和严格的考核方式。3.公立医院院长职业化的PEST分析结果1)政策环境层面：我国公立医院职业化的政策导向,显示出由广义的卫生事业管理职业化、医院管理职业化向明确的医院院长职业化的发展历程。国家的相关文件和政策为改革提供政策保障,但管办不分、传统干部人事制度、公立医院行政化和院长行政级别等可能成为政治阻碍因素。2)经济环境层面：我国的市场经济体制环境、医疗市场竞争等促进院长职业化,但职业经理人市场不完善可能制约改革进展。3)社会环境层面：当前社会对职业化院长的接受程度逐步提高,院长职业化人文环境也在逐渐建立,但院长的传统思维仍然存在,且在一定程度上阻碍改革。4)技术环境层面：我国其他领域的职业化改革和国外院长职业化实践为我国改革提供借鉴,但目前诸如职业院长准入、选聘、考核、退出机制等缺乏统一规定,同时职业化院长潜在队伍来源基础较薄弱。4.公立医院院长职业化改革中的个人因素分析作为未来职业化院长主要来源的院长和中层管理者队伍在专业、学历等方面存在问题；更多的院长停留在经验管理层面,87.1%的调查对象管理知识与技能来源为工作经验,担任现职后平均接受2.06次管理培训；院长由于缺乏专业的管理知识和技能,对职业化改革影响程度为68.28分(满分为100分,下同)；68%的调查对象认为职业化改革有必要,但改革可行性回答得分较低(均值57.96),其中60分以下占64.2%。通过对调查对象职业化意愿的个人因素回归分析发现,调查对象所在医院级别(OR=1.662,P=0.016)、性别(OR=0.632,P=0.020)、年龄(OR=00.632,P=0.020)、对我国实行职业化院长是否必要判断(OR=0.680,P=0.005)、个人对改革可行性判断(OR=1.663,P=0.000)、个人对专职管理工作兴趣程度(OR=0.370,P=0.000)、个人对自己个性能力与职业化院长适合程度判断(OR=0.364,P=0.000)是主要个人影响因素。5.公立医院院长职业化改革中的结构因素分析本研究将结构因素划分为政府、市场和医院三个层面。管理体制是影响改革的最大障碍；在列举的各种可能对公立医院院长职业化改革产生影响的结构因素中,影响程度评价得分评均高于60分,其中院长管理水平和技能缺乏、以及卫生管理人才匮乏影响评价相对较低,而现行院长选拔任用制度和医院缺乏用人自主权得分最高,中层管理者对结构因素带来的影响得分要高于院长。医院和卫生行政部门的管办不分对改革影响较大,30.5%的人为影响程度达到了80分以上。6.公立医院职业构建院长胜任力模型框架本研究从基准胜任力和鉴别胜任力两个维度构建职业化院长的胜任力模型框架。基准胜任力包括必备职业知识与技能、职业经验积累、工作投入、职业素养四个层面,鉴别胜任力包括社会与团体维持能力、组织目标达成能力和优秀管理者特殊个性特征三个层面,每个层面中又包含若干评价指标。对策建议：本研究较为系统地提出我国公立医院院长院长职业化的制度安排与支撑环境。制度是一种行为规则,更多地是一种正式约束,制度建设中那些非正式约束,也可以纳入制度构建的范畴。因此,要实现公立医院院长职业化改革,应做到：1.公立医院院长职业化改革是一个不断探索和改进的过程,应实行改革的逐步实现策略,将整个过程划分为三个解冻期、过渡期和稳定期三个阶段,每个步骤抓住各自的改革重心,确定合适的医院实行适宜的职业化改革策略,采取多样化的职业化改革实践形式。2.构建公立医院院长职业化的制度范畴体系：从内到外包括三大层次：最核心的是制度装置,其次是制度安排,最外部是制度环境和制度基础,三个层次之间相互影响。3.公立医院院长职业化改革的制度基础：包括职业化改革的政治经济基础、公立医院法人治理结构、法制基础和职业化院长市场化。4.公立医院院长职业化的制度安排。制度安排作为职业化制度的具体化,在实施需要非正式制度的支撑。正式制度安排包括职业院长的选拔、考核、激励和监督制度,非正式制度安排包括营造良好的舆论导向和建立职业化的激励性组织文化。5.营造和构建公立医院院长职业化改革的支撑环境,本研究提出在公立医院院长职业化改革中要建设好社会需求与保障环境、职业人孕育环境、职业道德环境和医院院长职业化环境等,以提供扎实和稳定的环境基础。论文创新之处1.理论意义与政策价值：公立医院院长职业化改革是公立医院改革的关键内容之一,对此方面开展系统研究具有紧迫性和实践意义。本研究运用多学科研究方法,从医院管理机制创新的角度、立足于新医改背景,丰富公立医院院长职业化改革的理论基础,挖掘当前国情下院长职业化改革的影响因素,建构我国公立医院院长院长职业化的制度安排与支撑环境,这些研究结果对于我国公立医院院长职业化改革的实践具有重要的参考价值。2.本研究构建公立医院职业化院长胜任力模型,提出院长基准胜任力和鉴别胜任力的维度与指标,该研究结果可以为将来我国职业院长的选拔资格和准入制度提供参考借鉴；同时论文结合社会角色期望理论,对职业化改革后的院长角色进行定位和管理设计,该研究成果具有一定的创新性和现实意义。更多还原

【Abstract】 ObjectivesPromoting the specialized and professionalized construction of hospital director is not only an important guarantee for the maintenance of public welfare in public hospitals, but also an important thrust of the deep reform in public hospitals. In intense medical market competition, the importance of hospital director of the public hospitals is increasingly prominent as key factors by grasping the mainstream of market competition and the activities directly involved in the operation and management. Hospital director’s professionalism will have a direct impact on the economic and social benefits of the public hospitals, and even affect the future and destiny of the public hospitals. Professionalization of hospital director in Chinese Public hospitals becomes an inevitable choice. The practical experiences of the developed countries show the feasibility of the professionalization of hospital director, which we could learn for our practice. In this dissertation, the professionalization of hospital director of public hospitals was researched. Through research, it was expected to improve the theoretical system, analyze the macro-political environment of the reform in-depth, refine and dig the key sectors and factors which may block the reform. Meanwhile, it was expected to propose competency model of professionalized hospital director to build the institutional arrangements and support environment for the reform of the professionalization of hospital director of public hospitals, which conform China’s national conditions, meet the reform needs of the professionalization.Methods:Theory discussion and demonstration research are the main methods in this article, combining with qualitative and quantitative study. At first, basing on a’great amount of documents, the article carries on documentary analysis, and combined many theories such as career theory, social role theory, governance theory etc to analysis the theories of professionalization reform of hospital director in public hospital. Secondly the author designs the research programme, did investigatigationg in 19 hospitals in Shandong province. Sample volume including 82 hospital directors and 595 middle managers.All data were input by SPSS 13.00. The article used some statistical analysis methods such as descriptive statistics, chi-squared analysis and logistic analysis. At last the article analysis the results of Key informan interview, also including some policy documents, gray literature, etc.Results1. Definition of professionalization of public hospital directorThe professionalization of the public hospital director is a combination of process and results. From the processes, reform of professionalization means reform of all angles of the career concept, career system, occupational environment, and professional team building, etc. to provide the driving force. From the results, professionalization means professionalized hospital director is accepted by law as an independent social career, and achieved gradually improved market of professionalize hospital, professionalization of hospital director’s value-orientation, professionalized quality, market-oriented configuration, non-official identity, and social recognition.2. Categorization and design of social role of the professionalized hospital director The role of professional hospital director is usually from the interactive relationship with public hospitals, government departments, other social organizations, and the public. As a role model which can adapt to social expectations, role categorization must combine with the macro, meso and micro perspective, to define and identify the expected connotation of the new role from multi-dimensional relation, such as government and society, hospitals and individuals, etc. From the entire design, professionalized hospital director takes management as life-long career, which has strict market entry and exit rules, obtain the right to use the hospital legal property, manage hospital as the legal status of the operator, achieve economic efficiency of hospital and social objective through using his professional management skills.3. Analysis results of PEST1) Level of policy environment:The policy-oriented professionalization of public hospital in China shows a developmental from a general professionalized management of public health and hospital to the definite hospital director professionalization. The national relevant documents and policies provided policy guarantee for the reform. But the regardless of management and service, the traditional cadre and personnel system, the administration of public hospitals and the executive level of hospital director, etc. becomes political obstacles.2) Level of economic environment:Professionalization of hospital director can be promoted by market economic system environment, health market competition, etc., but the imperfections of professional managers market, and the intervention of managers market by government administrative may limit the progress of the reform.3) Level of social environment:Although the social acceptance of the professionalized hospital director is gradually increased, and the human environment of professionalization of hospital director is gradually established, the thinking of traditional hospital director still exists, and to some extent hindered the reform.4) Level of technical environment:It provided reference for China’s reform by other industry professionalization reform and the practice of foreign hospital director professionalization, but it still lacks uniform requirements for professionalized hospital director in terms of access, selection and appointment, evaluation, exit mechanism, etc., currently.4. Analysis of individual factors in the reform of professionalization of public hospital directorAs the main sources of professionalized hospital director hospital director and middle managers team has some problems in their academic and degree. Many hospital director still stay in the experienced management levels,87.1% of respondents’ management knowledge and skills derived from their work experiences, and they received training in an average of 2.06 times at their present management. Because hospital directors lack of professional management knowledge and skills, the affected degree of the reform of professionalization was 68.28 points.68 percent of those polled said that professionalization reform was necessary, but the lower scored the feasibility of reform (mean 57.96), of which under 60 points accounted for 64.2%. Regression analysis on the willingness of the professionalization showed that major personal influence factors including hospital level where the survey work at (OR=1.662, P=0.016), gender (OR=0.632, P=0.020), age (OR=0.632, P=0.020), judgment on the necessity of implementing the professionalize hospital director in China (OR=0.680, P=0.005), Personal judgment on the feasibility of reform (OR=1.663, P=0.000), extent of personal interest in full-time management (OR=0.370, P=0.000), and judgment on the suitability of their own personal capacity and personality meet to professionalized hospital director (OR=0.364, P=0.000).5. Analysis of structural factors in the reform of professionalization of public hospital directorIn this dissertation, structural factors are divided into three levels, government, markets and hospitals. In various enumerated structural factors which may impact the reform of the public hospital director professionalization, the average score of evaluation of impact extent was higher than 60 points. The average score of evaluation of the lack of management level and skill, as well as the lack of the health management personnel was relatively low. The current selection and appointment system on hospital director and the lack of the employing autonomy in hospitals get the highest score. The score of evaluation of the middle-level cadre impact on structural factors is higher than the hospital director. The regardless of management and service in hospitals and health administration departments has larger impact on the reform.30.5 percent of the anthropogenic impact has more than 80 points.6. Construction of the competency model framework of professionalized public hospital directorIn this study, the competency model framework of professionalized hospital director was constructed from two dimensions in reference competence and identifying competency. Reference competency includes four levels, essential management knowledge and skills, accumulation of professional experience, job input, and professionalism. Identifying competency includes three levels, the maintain ability of societies and groups, the ability of obtaining organizational goals, and special personality traits for excellent managers. In each level, it also contains a number of evaluated indexes.Suggestions:This dissertation systematically proposed the institutional arrangements and the support environment for our country’s professionalization of public hospital director. Institution is the rules of conduct, and it is the formal constraints in more extent. In institution construction, those informal constraints can also be included in the areas of institution construction. Therefore, to achieve the reform of professionalized of the public hospital director, it should be done:1. Construction of institutional category system of professionalized public hospital director consists of three layers:the core is the institution device, followed by institutional arrangements, the most external institutional environment and institutional basis. It has mutual influence between the three levels. 2. Institutional basis of the professionalization reform of public hospital director includes political and economic foundation for professionalization reform, legal governance structure in public hospitals, related laws and regulations and market-oriented managers.3. Institutional arrangements for professionalized public hospital director:as a specific of professionalize system Institutional arrangements needs the supporting by the informal system in the implementation. Formal institutional arrangements include selection, evaluation, motivations and supervision system for professionalized hospital director. Informal institutional arrangements include creating a favorable public opinion, and building professionalized incentives organizational culture.4. Construction of supporting environment for professionalized of public hospital director:The construction of institution environment should proceed to the construction of institutional environment, social needs environment, legal environment, social security environment, occupational people birth environment, social credit environment and hospital professionalize environment.Innovation(1)Because there is lack of systematical research on the professionalization of public hospital director, so this article utllizes the theory of career theory, social role theory, and governance theory etc, based on the perspective of the hospital management innovation to make a systematical analysis. Definites of professionalization of public hospital director, discovers the different core work on different stage, digs the affect factors about individual and structure, and constructs the competency model framework of professionalized public hospital director.(2)The research bases on China state, it provides policy and practical support of how to guide the innovation of professionalization of public hospital director. Especially the research outcome of competency model and policy arrangement.Besides that, the article categorizes and design of social role of the professionalized hospital director.更多还原