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系統識別號 U0026-0812200915035471
論文名稱(中文) 臺灣醫院經營者壓力來源之探討與因應之道
論文名稱(英文) The challenges and resolution of hospital management in Taiwan
校院名稱 成功大學
系所名稱(中) 高階管理碩士在職專班(EMBA)
系所名稱(英) Executive Master of Business Administration (EMBA)
學年度 97
學期 1
出版年 98
研究生(中文) 李正揚
研究生(英文) Cheng-Yang Lee
學號 R0794419
學位類別 碩士
語文別 中文
論文頁數 50頁
口試委員 指導教授-吳萬益
口試委員-林炳文
口試委員-林清河
召集委員-陳志鴻
中文關鍵字 核減率  總額制度  醫療糾紛  醫院評鑑  醫院經營  健保制度 
英文關鍵字 hospital accreditation  National Health Insurance policy  global budget  medical disputes  Hospital management  deduction rate of claims 
學科別分類
中文摘要 臺灣的健康照護擁有五項世界之最,包括最方便、最自由、最經濟、最有效率及最高民眾滿意度,是令人引以為傲的臺灣奇蹟。在臺灣的健保經費支出,僅占GDP的百分之五,遠低於美國的百分之十二、德國的百分之十與日本的百分之七,如此傲人的廉價優質服務,是如何辦到的?這屬於醫界的光榮史,其實是荊棘滿布、壓力重重的辛酸史!筆者經營地區醫院十餘年,感受到經營壓力與日俱增,周遭醫界同仁莫不怨聲載道,於是企圖凝聚醫界的聲音,將諸多的壓力因素做一總整理。本研究主要目的在於探討臺灣醫院經營者承受的壓力有那些?各級醫院對壓力的承受力有何不同?地區醫院大量倒閉的主因為何?如何解決這諸多的巨大壓力?
本研究共分為三階段,第一階段為專家訪談,訪問各級醫院的正、副院長與高階主管共11 人,整理並條列專家們於經營中感受到的各種壓力因素;第二階段則做專家問卷調查,採AHP 層級分析法,共計三層,30 個壓力因素。研究結果發現,經營壓力以「外部因素」大於「內部因素」;其中「外部因素」的「健保制度」與「醫院評鑑」分別位居第一位與第二位,「內部因素」的「財務壓力」與「醫療糾紛」分別位居第三位與第四位;第三階段則進行全國性的問卷調查,以前述專家問卷的第三層30 項壓力因素條列為問卷,採李克特七點態度量表,寄發全國營運中的482 家醫院,回收有效問卷280 份,回收率為58.1%;運用SPSS 軟體,並與第二階段專家問卷產生的權重轉換運算,將醫院依舊制分為三組,即「醫學中心」、「區域醫院」與「地區醫院」,採多變量分析法,結果發現醫學中心在「財務壓力」、「醫事人力」、「醫療品質」、「競爭者」及「法律規範」與其他層級醫院有顯著不同,壓力較小;在「醫院評鑑」、「醫療糾紛」與「健保制度」中的「總額制度」與「核減率」雖無顯著不同,
但是從壓力量表的平均數得知,三個層級的醫院均感受到巨大壓力。而將私人經營的地區醫院與其他性質的醫院,區分為兩組,行平均樣本T 檢定,私人醫院除上述共同壓力外,在「財務壓力」、「醫事人力」、「醫療品質」及「競爭者」方面,壓力亦遠大於其他醫院,間接說明了地區醫院大量萎縮的原因!
綜合本研究之結果,經營壓力以地區醫院為巨,因此在惡劣環境下應聲倒地,政府若對這些汲汲不保的小醫院及時伸出援手,以醫療照護的可近性而言,是當務之急。然而地區醫院本身亦應檢討,強化自身競爭力,善用支源醫師制度,以改善醫師人力問題,功能標準化,不必購買昂貴的儀器設備,充分與大型醫院合作,雙向轉診;國家政策若能配合,「醫療分級,保費分級」,以適度調整保費收入,將全民「健康」保險正名為「疾病」保險,健康自己負責,生病時才倚賴國家;再者,「大醫院管疾病,小醫院管健康」,醫學中心及大型醫院著重於急重症治療,成人健檢、兒童健檢等應委由地區小醫院執行。「醫療糾紛」納入健保,所衍生的費用,由健保局提供專款專用。調整民眾就醫心態,適度開放媒體介紹當地醫療院所,民眾若能充分瞭解當地的就醫資訊,何苦舟車勞頓、捨近求遠?地區醫院問題解決了,其餘陳疴或可迎刃而解。
英文摘要 Taiwan's health care system is one of the best in the world in terms of convenience, freedom of choice, affordability, efficiency and patient satisfaction. It's a great achievement that Taiwan can be proud of. While its health insurance expenditures account for only 5 percent of GDP, far below the United States'12, Germany's 10 and Japan's 7 percent. It makes people wonder how these superior yet cost effective services can be achieved. However, many unfortunate details underlying this seemingly perfect system are mostly ignored. The author has operated a local hospital for more than 16 years, and has witnessed the ever-increasing strains placed on management and medical staffs, but there is seldom public expression of these frustrations. This report will collect the opinions of medical personnel throughout the country and analyze the pressures on the medical community scientifically. Thus the ultimate goals of this research is to expose the pressures of hospital management in Taiwan, to analyze how hospitals of varying grades handle these pressures, to investigate the causes of mass closures among local hospitals, and to present possible solutions to this situation.
This study was divided into three stages. The first stage consisted of in-depth interviews with 11 experts including presidents, vice presidents and top executives from hospitals of all grades to compile the possible sources of pressure faced by medical communities. The second stage involved conducting surveys with questionnaires by the 11 aforementioned experts. This study covered a total of three levels with 30 pressure factors. Using AHP-level analysis, the main findings showed that business pressures originating from the "external environment" were higher than those from the “internal environment”. External environmental factors such as the "National Health Insurance policy" and "Hospital Accreditation" were ranked the first and the second place, while internal environmental factors such as "financial pressure" and "medical disputes" were ranked the third and the fourth. The third stage was a national survey of all the hospitals operating in the country with the questionnaires which originated from above 30 pressure factors. They utilized the Likert 7 scale to analyze the responses toward management stress. This survey was sent to 482 hospitals operating in the country. Two hundred eighty valid questionnaires were recovered, a response rate of 58.1%. Utilizing the statistical software SPSS, along with the the weight conversion operation derived from the second stage. The hospital system was categorized into three distinct groups, the "Medical center", "Regional hospital" and "Local hospital". Through adopted multi-variable analysis, results revealed that the scores of "financial pressure"、"medical manpower"、"quality of medical care"、"competitors", and "the law stands" in the "Medical center" group were significantly lower compared to the other 2 groups. Scores of "Hospital Accreditation"、"medical disputes" and "Global budget" / "Deduction rate of claims" under the "National Health Insurance policy" were not significantly different in all of the three-grade hospitals, but the average scores of the pressure factors indicated all hospitals were experiencing tremendous pressure. When hospitals were reclassified into two groups: private-owned local hospitals vs. other hospitals, the T-test revealed that in addition to the above-mentioned pressure factors, the categories of "financial pressure"、"medical manpower"、"quality of medical care" and "competitors" in private local hospitals were also tremendous. The fact indirectly explained why a large number of private local hospitals had gone out of business.
In conclusion, the management pressures tops on local hospitals which are vulnerable during these current unfavorable circumstances. If the government can grant the proper assistance in time, the rate of hospitals closing down will be slowed, and a quick and effective medical care system can be maintained. On the other hand, the local hospitals should strengthen their competitiveness, make the best use of support physician systems to ease the load on manpower, to locate clear on their function, avoid unnecessary facility purchases, to collaborate with medical centers and put a two-way referral system into effect. The government may adjust the national health insurance fee to a graded structure. ‘The National "Health" Insurance’ should be renamed ‘The National "Disease" Insurance’. People manage their own "health", whereas the government only involve in treatment of serious illness. If the "adult health examination" and "child health examination" were assigned to the local hospitals, medical centers and regional hospitals could focus on severe and emergency medical care. Moreover, the NHI should cover the expenses of medical disputes by seting up an independent fund. Facilitate media institutions to introduce local medical resources, let the people get a clear picture of local hospitals and make use of, so they will save the travelling time and expenses to the medical center. If the problems of local hospital resolved, all the pressures to be readily solved!
論文目次 摘 要 .............................................................................................................................. I
ABSTRACT ........................................................................................................................ II
誌 謝 ........................................................................................................................... III
表 目 錄 ............................................................................................................................ II
圖 目 錄 ........................................................................................................................... III
第一章 緒論 ..........................................................................................................................1
第一節 研究動機-------------------------------------------------------1
第二節 研究背景-------------------------------------------------------1
1. 醫院的特殊性質----------------------------------------------3
2. 我國醫療機構的演進------------------------------------------3
3. 健保制度----------------------------------------------------4
4. 醫院評鑑----------------------------------------------------5
第三節 研究目的 ...................................................... 6
第二章 文獻探討 ..................................................................................................................8
第一節 壓力的定義-----------------------------------------------------8
第二節 經營壓力定義---------------------------------------------------9
第三節 醫院經營壓力因素-----------------------------------------------9
第三章 研究方法 ................................................................................................................20
第一節 研究流程------------------------------------------------------20
第二節 專家訪談------------------------------------------------------21
第三節 AHP層級程序分析法---------------------------------------------24
第四節 李克特氏量表--------------------------------------------------25
第四章 研究結果與討論 ....................................................................................................26
第一節 專家問卷分析--------------------------------------------------26
第二節 全國性問卷分析------------------------------------------------28
第五章 結論與建議 ............................................................................................................36
第一節 臺灣醫院經營者壓力種類----------------------------------------36
第二節 各級醫院對壓力反應的異同--------------------------------------37
第三節 地區醫院萎縮的原因--------------------------------------------37
第四節 解決巨大壓力的辦法--------------------------------------------38
1. 地區醫院自身的檢討-----------------------------------------38
2. 政府醫療政策的支持-----------------------------------------39
3. 民眾就醫心態的調整-----------------------------------------41
附錄一:問卷 ......................................................................................................................42
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四十六 鄧振源、曾國雄(1989)網路
四十七 【大紀元4 月17 日報導】本文網址: http://www.epochtimes.com/b5/8/4/17/n2085280.htm
四十八 沈富雄(2005)如何讓健保免於破產 網路
四十九 【大紀元4 月17 日報導】本文網址: http://www.epochtimes.com/b5/8/4/17/n2085280.htm
五十 葛謹 英國醫療糾紛案例之啟示 臺灣醫界 2008,Vol.51,No.8
五十一 新谷弘實 2007 不生病的生活實踐篇 如何出版社
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