基于PATH模型的安徽省县级公立医院绩效评价实证研究

发布时间：2018-03-24 18:49

本文选题：基本药物制度　切入点：县级公立医院　出处：《安徽医科大学》2017年硕士论文

【摘要】：背景2012年以来,在县级公立医院基本药物制度和相关改革举措不断深入推进的同时,建立能够突出功能定位和社会效益的县级公立医院绩效考核制度已逐渐成为公立医院改革的重要战略任务之一。然而,目前以县级公立医院为评价对象,以公立医院综合改革成效考评为背景的综合绩效评价实证研究较少。因此,建立一套以公益性为核心,适合卫生行政部门对公立医院进行监管和考核、满足多元化利益主体需求的绩效评价体系,并运用科学绩效评价方法对县级公立医院开展绩效评价显得尤为必要和迫切。本研究旨在运用前期构建的绩效评价指标体系,对安徽省县级公立医院开展绩效评价实证研究,了解县级公立医院改革前后医院运行和绩效变化情况,发现各医院发展优势和薄弱环节,探讨绩效结果变化及相互间绩效差异的原因,并提出针对性的对策建议,为进一步完善县级公立医院绩效评价工作以及卫生行政部门科学决策提供参考和依据。方法采用文献复习法和专家咨询法,设计县级公立医院绩效评价系列调查表和访谈提纲;采用现场调查法,在安徽省21个首批县级公立医院综合改革试点县中,根据地域分布,在皖南、皖中、皖北各随机抽取4家(共12家)县级公立综合医院作为调查现场,利用自行设计的调查问卷,对样本医院2011年和2015年相关数据进行回顾性调查。采用Epidata 3.1、Excel对定量数据进行双录入,使用SPSS16.0进行数据分析。运用构成比、增长率等对12家医院改革前后整体运行指标变化和各医院2015年运行现况进行描述性分析;运用加权TOPSIS法进行各维度绩效和综合绩效评价。结果(1)人力资源状况:2015年,12家医院职工总数为8637人,较2011年增长27.94%(年均增长率为6.35%);其中,卫生技术人员、大专及以上、硕士及以上、高级职称人员分别占82.19%、74.59%、1.54%、3.70%,较2011年分别增加0.93、10.66、0.99、0.07个百分点,注册护士数量及占比增幅较大,大专以上人员数量增长明显,高素质人员占比不足。医护比、床护比分别为1:1.54和1:0.51,较2011年均略有增减。(2)医疗服务能力:2015年,12家医院实际开放床位7041张,较2011年增长44.28%(年均增长率为9.60%)。医疗服务总量、门急诊人次、出院人次分别为415.64万人次、384.87万人次、31.73万人次,较2011分别增长69.64%、72.22%、47.24%,年均增长率分别为14.13%、14.56%、10.16%,门急诊人次增速较快。(3)经济运行状况:2015年,12家医院财政补助收入、医疗收入、药品收入占总收入比例分别为7.17%、54.28%、35.81%,较2011年分别增长0.59、5.80和-7.55个百分点,改革后,财政补助收入、医疗收入占总收入比例较改革前增加,药品收入占比减低。2015年,医疗业务成本、管理费用支出、财政项目支出占总支出比例分别为84.48%、12.32%、2.76%,分别较2011年降低1.26、2.02、0.39个百分点,药品费用占比由41.88%降低为36.71%,降低5.17个百分点,改革后药品费用占比变化较大。2015年,总收支结余较2011年有所增加,增幅为22.18%;业务收支结余较2011年显著降低,降幅为86.87%;财政补偿收支结余较2011年明显增加,增长率为132.20%。(4)患者为中心维度:2015年,各医院均建立了医患沟通制度、医疗服务流程制度。住院患者满意度为96.12%,较2011年提高1.72个百分点。术前平均待床日为2.29床日,较2011年增加0.11床日;10分钟内急会诊反映达标率均保持在99.0%以上,医疗服务可及性尚可。(5)公益性为导向维度:2015年,次均门诊费用206.89元,较上年增长率为3.52%,其中次均门诊药品费用占42.78%,较2011年降低2.54个百分点;次均住院费用4943.49元,较上年增长率为7.32%,其中次均住院药品费用占38.21%,较2011年降低9.91个百分点。2015年,城镇职工住院患者补偿比为78.63%,较2011年降低0.56个百分点,变化幅度微小;城乡居民住院患者补偿比为61.46%,较2011年增加5.30个百分点,增幅较大。2015年,国家基本药物配备率为50.13%,较上年增长7.43个百分点,国家基本药物采购金额比例19.73%;带量采购实施后,政策性亏损得以充分弥补,绝大多数药品也能及时供应。(6)医疗质量与安全维度:诊断、治疗、护理、医院感染、安全管理方面,绝大多数指标均控制在较好水平,且符合综合医院管理标准,但部分核心指标控制仍不理想。2015年,剖宫产率由2011年55.11%降低至2015年49.64%,护理文书书写合格率由95.68%增至97.17%,建立重点药品监控制度的医院数量由4家增至9家;住院患者抗菌药物使用率由71.93%降低至62.04%;Ⅰ类切口手术患者预防性使用抗菌药物比例降低至76.22%(降7.43个百分点),手卫生依从率由42.88%增至57.09%,以上指标仍未达到相关管理标准。(7)效率与效益维度:2015年,人员支出占总支出比例为30.54%,比2011年增长6.22个百分点;平均每职工年业务收入为28.21万元,比2011年增长8.82万元。管理费用占总支出比例由14.35%降低至12.32%;业务收支结余率降低明显,2015年为0.28%,较2011年降低3.68个百分点;资产收益率、净资产收益率有所下降,分别由5.24%降至3.39%、8.45%将至12.43%,改革后资产收益能力略有降低。医师人均每日负担住院床日为2.70床日,较2011年增加0.18床日;医师人均每日负担诊疗人次数有所增加,由4.90人次增至6.55人次,表明工作效率提高,工作负荷增大。2015年,4家医院床位处于高效率运行状态,8家处于低效率运行状态。(8)员工维度:2015年,职工教育(培训)投入占业务收入比例0.14%,较2011年下降0.07个百分点,职工教育(培训)投入严重不足。医护进修人员比例3.52%,较2011年增长0.75个百分点,进修人员不足。2015年医护人员满意度92.68%,较2011年增加0.30个百分点。(9)医院发展维度:2015年农合患者出院人次占县域内出院人次比例35.07%,较2011年增长5.17个百分点,改革后县域医疗服务能力有所提升;市级及以上重点学科、特色专科数13个,较2011年增加10个,改革后重点学科、特色专科建设得以加强。2015年政府投入占医院总支出比例7.53%,较2011年增加0.41个百分点,政府投入增量不足;净资产增长率13.77%,较2011年降低6.21个百分点,改革后净资产有所减少;资产负债率44.60%,较2011年增加4.05个百分点(2012年为51.86%),改革后资产负债率高于改革前,但呈降低趋势;业务收入增长率10.06%,较2011年降低7.07个百分点,改革后业务收入增速减缓。2015年信息化建设和利用度69.05%,较2011年增加54.76个百分点,信息化服务能力增强。(10)综合绩效评价:2015年综合绩效值明显高于2011年,县级公立医院改革成效得以体现。公益性为导向、质量与安全、效率与效益、发展4个维度绩效值均高于改革前,而患者为中心、员工2个维度绩效值低于改革前。2015年,D医院综合绩效最高,G医院次之,J医院最低,除前2名外,其它各医院之间绩效差异较小。结论(1)服务能力得以提升,但县域服务总量仍不高(2)卫生人力资源总量增加,但优质资源缺乏,结构不合理(3)医院经济运行总体平稳,收支结构发生改变,但政府投入依旧不足(4)医药费用上涨得以控制,但患者整体费用获益感并不明显(5)药品采购机制初步建立,仍需进一步细化(6)医疗质量与安全总体良好,管理机制有待完善(7)床位工作效率有待改善(8)员工待遇条件得以改善,但积极性提升制约因素依然存在(9)绩效评价指标体系及方法可操作性强,需进一步深入研讨建议(1)加强县域医疗卫生服务体系规划,促进医院健康发展(2)完善政府投入机制,保障公益性落实(3)合理调整医疗服务价格,体现医务人员价值(4)改革医保支付方式,增强医保杠杆作用(5)加强医院自我管理,提高自我补偿能力(6)完善人事与薪酬分配制度,提高人员积极性(7)改善患者就医感受,提高患者满意度(8)加强医疗质量管理,保障医疗安全(9)加强信息化建设,提高医院管理效率(10)完善绩效评机制,提高绩效评价效能
[Abstract]:Background since 2012, in the county public hospital system of basic drugs and related measures to promote the deepening of reform and the establishment of performance appraisal system of public hospitals in the county can highlight the function and social benefits has gradually become an important strategic task of the reform of public hospitals. However, the current county public hospital as the evaluation object, the evaluation results of comprehensive the reform of public hospital comprehensive performance evaluation of the background of empirical research is limited. Therefore, to establish a set of public welfare as the core, for the public health administrative departments for supervision and assessment of public hospital performance evaluation system, to meet the demand of diversification of interests, and use the scientific method of performance evaluation of public hospitals in the county to carry out performance evaluation is particularly necessary and urgent the purpose of this study is to use pre construction. The performance evaluation index system of the county public hospital of Anhui Province, the development of performance An empirical study on the efficiency evaluation, understand the change of hospital operation and performance before and after the reform of public hospitals in the county, the hospital found that the development of advantages and weaknesses, to explore the causes of changes and differences between the performance of performance results, and put forward the countermeasures and suggestions, and provide reference for the further improvement of the performance evaluation of public hospitals at the county level and the administrative department of health scientific decision-making. Methods by means of literature review and expert consultation, design of county public hospital performance evaluation questionnaire and interview outline series; through the survey, in Anhui Province, the first batch of 21 County Comprehensive Reform of public hospitals in the county, according to geographical distribution, in Anhui, Anhui, Anhui were randomly selected 4 (total 12) the county public hospital as the investigation site, using a self-designed questionnaire, the sample hospitals in 2011 and 2015 data were retrospectively The survey by Epidata. 3.1, Excel double entry of data, data were analyzed using SPSS16.0. The constituent ratio, growth rate of change of operation index before and after the reform of 12 hospitals in the whole and the operation situation of the hospital in 2015 were analyzed with weighted TOPSIS method; the dimensions of performance and comprehensive performance evaluation results (1). Human resources: 2015, 12 hospitals and 8637 employees, an increase of 27.94% compared to 2011 (the average annual growth rate of 6.35%); among them, health professionals, college degree or above, master degree or above, senior professional titles accounted for 82.19%, 74.59%, 1.54%, 3.70%, compared to 2011 increased by 0.93,10.66,0.99,0.07 percentage points, registered nurses the number and proportion of the larger increase in number of college personnel increased significantly, high-quality personnel accounted for less than. The ratio of doctors to nurses and nursing bed were 1:1.54 and 1 respectively.:0.51, a slight increase or decrease (at an average annual rate of 2011. 2) the ability of medical services: 2015, 12 hospitals with 7041 beds, an increase of 44.28% compared to 2011 (the average annual growth rate of 9.60%). The total amount of medical services, outpatient, hospital visits were 4 million 156 thousand and 400 passengers, 3 million 848 thousand and 700 passengers, 317 thousand and 300 passengers, compared with 2011 growth of 69.64%, 72.22%, 47.24%, the average annual growth rate were 14.13%, 14.56%, 10.16%, outpatient rapid growth. (3) the economic situation: in 2015, 12 hospitals financial subsidy income, medical income, drug income total income ratio was 7.17%, 54.28%, 35.81%, compared with 2011 growth of 0.59,5.80 and -7.55 percentage points, respectively, after the reform, the financial subsidy income. The medical income total income ratio increased compared to before the reform, the proportion of drug income decreased.2015 years, medical service costs, management costs, financial expenditure total expenditure ratio were 84.48%, 12.32%, 2.76%, respectively, compared with 2011 down Low 1.26,2.02,0.39 percentage points, the proportion of drug costs decreased from 41.88% to 36.71%, 5.17 percentage points lower, after the reform of drug costs accounted for large changes in.2015 years, the total balance of payments increased in 2011, an increase of 22.18%; the balance of business than in 2011 decreased significantly, a decline of 86.87%; the balance of financial compensation than in 2011 increased significantly the growth rate of 132.20%. (4) patients as the center dimension: 2015, hospitals have established the system of doctor-patient communication, medical service process system. The satisfaction rate of hospitalized patients was 96.12%, compared to 2011 increased 1.72 percentage points. The average preoperative stay for 2.29 days on the bed bed, an increase of 0.11 compared to 2011 on the bed; 10 minutes call consultation reflect the compliance rate remained above 99%, accessibility of medical services is acceptable. (5) public welfare oriented dimensions: in 2015, the average outpatient expenses of 206.89 yuan, representing a growth rate of 3.52%, the average outpatient drug Costs accounted for 42.78%, 2.54 percentage points lower than in 2011; the average hospitalization cost of 4943.49 yuan, representing a growth rate of 7.32%, the average hospitalization expenses of drugs accounted for 38.21%, 9.91 percentage points lower than in 2011.2015 years, urban workers hospitalized patients compensation ratio of 78.63%, 0.56 percentage points lower than in 2011, small changes; urban and rural areas residents of inpatient compensation ratio of 61.46%, an increase of 5.30 percentage points higher than in 2011, a larger increase in.2015 years, the national basic drugs with rate of 50.13%, an increase of 7.43 percentage points over the previous year, the national essential drug procurement amount than in 19.73% cases; with the amount of purchase after the implementation of the policy to fully compensate for the loss, the vast majority of drugs can also be timely supply. (6) the dimension of medical quality and safety: the hospital diagnosis, treatment, nursing, infection, safety management, most indicators are controlled in a better level, and in accordance with the hospital management standard, but Part of the core control index is still not ideal for.2015 years, the cesarean section rate decreased from 55.11% in 2011 to 49.64% in 2015, nursing documents writing qualified rate increased from 95.68% to 97.17%, the number of the establishment of key drug monitoring system in hospital from 4 to 9; the rate of hospitalization decreased from 71.93% to 62.04%, the use of antibiotics in patients with type I; preventive use of antimicrobial the drug ratio is reduced to 76.22% incision surgical patients (down 7.43 percentage points), hand hygiene compliance rate increased from 42.88% to 57.09%, the above index has not yet reached the relevant standards of management. (7) the efficiency and effectiveness of dimensions: 2015, staff expenditure accounted for the proportion of total expenditure was 30.54%, up 6.22 percentage points higher than in 2011; average revenue per employee the year was 282 thousand and 100 yuan, up 88 thousand and 200 yuan more than in 2011. Management costs accounted for the proportion of total expenditure decreased from 14.35% to 12.32%; the business balance rate was decreased to 0.28% in 2015, compared to 2011 decreased by 3.68 %; return on assets, net assets yield decreased, respectively from 5.24% to 3.39%, 8.45% to 12.43%, asset profitability decreased slightly after the reform. The physician daily burden of hospital beds per capita, 2.70 bed, 0.18 bed days increase compared to 2011; physicians per capita daily burden of treatment times increased by 4.90 times to 6.55 people, shows that the work efficiency is improved, the work load increases.2015 years, 4 hospital beds in a state of high efficiency operation, 8 in a low efficiency state. (8) employees: 2015, employee education (training) investment proportion of business income of 0.14%, down 0.07 percentage points compared with 2011, the staff education (training) a serious shortage of investment in education. Medical staff ratio of 3.52%, an increase of 0.75 percentage points compared to 2011, for lack of staff.2015 staff satisfaction 92.68%, an increase of 0.30 percentage points compared to 2011. (9) the hospital development dimension: 2015 agricultural discharges within the county hospital patients accounted for 35.07% of the proportion of passengers, an increase of 5.17 percentage points compared to 2011, after the reform of county medical service ability increased; the municipal level and above key disciplines, the specialty of the number 13, increased 10 compared with 2011, after the reform of the specialty construction of key disciplines, to strengthen government investment for hospital.2015 a proportion of 7.53%, an increase of 0.41 percentage points higher than in 2011, the government investment increment is insufficient; the growth rate of net assets of 13.77%, 6.21 percentage points lower than in 2011, after the reform of the net assets decreased; asset liability ratio of 44.60%, an increase of 4.05 percentage points compared to 2011 (51.86% in 2012), after the reform of the balance is higher than before the reform, but decreased; the business income growth rate of 10.06%, 7.07 percentage points lower than in 2011, after the reform of business revenue growth slowed.2015 years of information construction and utilization of 69.05%, compared with 2011. Plus 54.76 percentage points, to enhance the competence of informatization service. (10) a comprehensive performance evaluation: comprehensive performance in 2015 was significantly higher than that in 2011, the effectiveness of the county public hospital reform reflected public welfare oriented, quality and safety, efficiency and benefit, the development of the 4 dimensions of performance value is higher than before the reform, while the patients as the center, staff the 2 dimensions of performance is lower than before the reform of.2015 years, D hospital comprehensive performance is highest, G times in the hospital, J hospital, in addition to the lowest, outside the top 2, between the hospital performance were smaller. Conclusion (1) the service ability can be improved, but the service is still not high (2) the total amount of health manpower resource increase, but the quality of the lack of resources, the unreasonable structure of the hospital (3) the economy is generally stable, balance of payments structure changed, but the government investment is still insufficient (4) the rise of medical expenses can be controlled, but the overall cost of patients benefit sense is not obvious (5) drug procurement mechanism Step up, still need further refinement (6) medical quality and safety is generally good, needs to improve management mechanism (7) beds efficiency needs to be improved (8) conditions to improve the treatment of employees, but to enhance motivation constraints still exist (9) evaluation index system and method of performance, strong operability, need further study suggestions (1) to strengthen the county health service system planning, and promote the healthy development of the hospital (2) to improve the government investment mechanism, to protect the public welfare implement (3) adjust the prices of medical service, embody the value of the medical staff (4) Medicare payment reform, strengthen Medicare leverage (5) to strengthen the hospital self management, to improve the self compensation (6) to improve the ability of personnel and salary distribution system, improve the enthusiasm of staff (7) to improve the patient's medical experience, improve patient satisfaction (8) to strengthen the medical quality management, ensure medical safety (9) to strengthen the construction of information technology, improve Hospital management efficiency (10) improving performance evaluation mechanism and improving performance evaluation efficiency

【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.3

【参考文献】