本文關鍵詞： 基層醫(yī)療機構(gòu) 績效管理 增量成本效果 投入產(chǎn)出分析　出處：《南京醫(yī)科大學》2016年碩士論文　論文類型：學位論文

【摘要】：研究目的：基層醫(yī)療機構(gòu)是我國衛(wèi)生服務提供體系的網(wǎng)底,是基本醫(yī)療服務和基本公共衛(wèi)生服務的主要提供者,其服務質(zhì)量與運行效率直接關系到城鄉(xiāng)居民能否享有安全、有效、方便、價廉的基本醫(yī)療衛(wèi)生服務以及整個衛(wèi)生服務體系的運轉(zhuǎn)效率。2009年新醫(yī)改啟動以來,政府在不斷提高基層醫(yī)療機構(gòu)財政投入的同時,積極試行機構(gòu)績效管理工作以合理引導,系統(tǒng)提升基層醫(yī)療機構(gòu)的綜合績效水平。然而國內(nèi)部分績效管理實踐卻提示績效管理工作管理成本高,給基層醫(yī)療機構(gòu)造成工作壓力,甚至影響機構(gòu)正常業(yè)務工作開展。為此,本研究站在基層醫(yī)療機構(gòu)的角度,測量參與績效管理前后基層醫(yī)療機構(gòu)相關成本投入以及綜合績效變動,利用增量成本效果分析衡量機構(gòu)績效管理投入產(chǎn)出效率,從而為推動績效管理工作順利開展,提升機構(gòu)綜合績效水平以及保障基層醫(yī)療衛(wèi)生機構(gòu)的平穩(wěn)運行發(fā)展提出建議。研究方法：以安徽省界首市18所基層醫(yī)療機構(gòu)作為研究對象,開展了定性與定量研究。定性調(diào)查包括面向16位基層醫(yī)療機構(gòu)負責人的績效管理座談會、面向4位中心衛(wèi)生院院長的深入訪談,以此獲得基層醫(yī)療機構(gòu)參與績效管理工作的內(nèi)容。定量調(diào)查包括收集2013年和2014年機構(gòu)衛(wèi)生財務報表、基于課題組自行設計的關鍵績效指標體系收集機構(gòu)連續(xù)兩年的績效數(shù)據(jù)、利用課題組自行設計的成本調(diào)查表收集績效管理前后機構(gòu)增量成本支出數(shù)據(jù)。本研究借鑒作業(yè)成本法的理念調(diào)查并歸集與機構(gòu)績效管理相關的成本耗費、利用模糊綜合評價法量化績效管理對基層醫(yī)療機構(gòu)的隱性影響、基于綜合指數(shù)法對機構(gòu)績效管理工作進行效果評價、采用增量成本效果分析評價基層醫(yī)療機構(gòu)參與績效管理工作的投入產(chǎn)出效率以及利用系統(tǒng)基模分析探索當前基層醫(yī)療機構(gòu)綜合績效提升阻礙因素以及增量成本效果差異的原因。研究結(jié)果：(1)機構(gòu)績效管理下,平均每所基層醫(yī)療機構(gòu)因參與績效管理工作需多支出38.7萬(顯性成本13.8萬,人力時間成本24.9萬)。86%的人力時間成本耗費在績效反饋與改進工作,91.3%的顯性成本為機構(gòu)院容院貌和科室設施設備支出。顯性成本支出占2014年機構(gòu)總支出2.56%。(2)雖然績效管理工作增加了基層醫(yī)療機構(gòu)工作壓力,但提高了機構(gòu)管理效率、工作積極性以及機構(gòu)聲譽等,量化分析表明隱性影響促進機構(gòu)總收入平均增加68萬,遠高于顯性成本與人力時間成本。(3)盡管界首當前并未規(guī)范地開展以績效持續(xù)改進和提高機構(gòu)綜合績效水平為目的績效管理工作,但2014年18所基層醫(yī)療機構(gòu)綜合績效水平平均增長了11,僅A06和C1兩所機構(gòu)綜合績效水平下跌(-9和-0.35)。相關分析結(jié)果表明機構(gòu)2014年績效指數(shù)與績效排名變動呈正相關,提示18所機構(gòu)存在較大績效提升空間(Pearson相關P value=0.002,R=0.680; Spearman相關P value=0.005, R=0.626)。(4)增量成本效果分析表明18所機構(gòu)提高單位績效指數(shù),需要增加投入3.6萬元(1.3萬顯性成本和2.3萬人力時間成本),一般衛(wèi)生院、在職職工人人數(shù)較少、總收支結(jié)余水平較差的機構(gòu)往往提高單位績效需增加的成本高于其他機構(gòu)。(5)基模分析表明基層醫(yī)療機構(gòu)硬件與軟件發(fā)展不協(xié)調(diào)限制了機構(gòu)績效產(chǎn)出增長上限；繁重的基本公共衛(wèi)生服務任務、有限的衛(wèi)技人員數(shù)以及薄弱的村室服務能力影響了機構(gòu)工作效率；基層醫(yī)療機構(gòu)薄弱的經(jīng)濟自我補償能力導致績效投入產(chǎn)出效率“強者越強”。政策建議：(1)不斷優(yōu)化機構(gòu)績效管理模式,創(chuàng)新績效考核方式,推進基層衛(wèi)生信息化建設等措施提高績效管理效率；(2)完善對基層衛(wèi)生人才的經(jīng)濟激勵與非經(jīng)濟激勵措施,提高基層衛(wèi)生人員數(shù)量素質(zhì),降低人才流失率；(3)加強財政對基層醫(yī)療機構(gòu)基礎設施設備、物理環(huán)境建設等投入,創(chuàng)新財政投入方式,積極為績效改進成本合理兜底；(4)衛(wèi)生局積極利用績效管理均衡基層醫(yī)療機構(gòu)醫(yī)療服務和基本公共衛(wèi)生服務,不斷強化基層醫(yī)療機構(gòu)服務功能建設。機構(gòu)院長積極拓寬思路,不斷提高醫(yī)療服務和基本公共衛(wèi)生服務效率。
[Abstract]:Objective: To study the grassroots medical institutions is our country health service system network is the main provider of basic medical services and basic public health services, the service quality and operation efficiency is directly related to urban and rural residents can enjoy safe, effective, convenient and inexpensive, since the basic medical and health services and the health service system operation efficiency.2009 years of the start of new medical reform, the government in the continuous improvement of grassroots medical institutions of financial investment, actively work to guide a reasonable performance management mechanism, system to improve the comprehensive performance level of grassroots medical institutions. However, the domestic part of the performance management practice has indicated that performance management work of high cost, resulting in the work pressure to the grassroots medical institutions, and even affect the mechanism the normal business work. Therefore, this research station in the basic medical institutions involved in the perspective of performance management and measurement Changes in basic medical institutions related to cost and performance, using the incremental cost-effectiveness analysis to measure the input-output efficiency of performance management mechanism, so as to promote the performance management work smoothly, suggestions to enhance the comprehensive performance level of development and smooth operation mechanism and the protection of basic medical and health institutions. Methods: in Anhui Province Jieshou City 18 primary medical institutions as the research object, carry out qualitative and quantitative research. Quantitative survey for 16 grassroots medical institutions responsible for the performance management forum for the 4 center hospital hospital long in-depth interviews, in order to obtain the basic medical institutions involved in performance management work. The quantitative survey collected in 2013 and 2014 including health financial statements. The performance data of the key performance index system designed by research team for two consecutive years collecting mechanism based on the use of The research group designed the questionnaire to collect the cost of performance management mechanism before and after the incremental cost expenditure data. The concept of activity-based costing and performance management mechanism investigation and collection related costs from this research, using fuzzy comprehensive evaluation method to quantify the performance management of recessive effect of grass-roots medical institutions, comprehensive index method is used to evaluate the effect of performance management mechanism based on the exploration of basic medical institutions comprehensive performance reasons hindering factors and incremental cost effectiveness analysis of the differences in basic medical institutions to participate in the evaluation of the performance management of the input-output efficiency by using the incremental cost effectiveness analysis and the use of system model. Results: (1) performance management mechanism, the average of each basic medical institutions for participation in performance management work requires the expenditure of more than 387 thousand (the dominant cost 138 thousand manpower costs 249 thousand).86% human Between the cost in performance feedback and improvement work, 91.3% of the cost for the dominant institutions courtyard Rong Yuanmao and Department of facilities and equipment spending. The dominant cost spending in 2014 accounted for the total body 2.56%. (2) although the performance management work to increase the working pressure of the grassroots medical institutions, but improve the efficiency of management mechanism, working enthusiasm and reputation mechanism etc. the quantitative analysis shows that, the recessive influence promotion agencies total income increased by an average of 680 thousand, much higher than the explicit cost and human cost of time. (3) although not currently carried out by Jieshou standard performance continued to improve and enhance the comprehensive performance level of institutions for the purpose of performance management, but the comprehensive performance level in 2014 18 local medical institutions rose by an average of 11 the comprehensive performance level of only A06 and C1 two institutions (-9 and -0.35) fell. Correlation analysis showed that the 2014 performance index and performance ranking changes were positively correlated, That 18 mechanism has improved greatly the performance (Pearson P value=0.002, R=0.680 P value=0.005 R=0.626; Spearman,). (4) show that the incremental cost effectiveness analysis of 18 institutions to improve the performance index, the need to increase the investment of 36 thousand yuan (13 thousand to 23 thousand human dominant cost and time cost), general hospital, all staff small number of the total balance of lower level institutions tend to improve performance to increase the cost is higher than other institutions. (5) show that the development of grassroots medical institutions, hardware and software of uncoordinated limit mechanism performance growth limit analysis of fundamental mode; the heavy task of basic public health services, the number of health personnel is limited and weak the ability of village room service affects the efficiency of institutions; the weak economic self compensation ability of grassroots medical institutions lead to the input-output efficiency "performance strong stronger political." Policy recommendations: (1) to optimize the performance management mechanism innovation, performance evaluation, and promote grass-roots health informatization construction and other measures to improve the efficiency of performance management; (2) improve the economic incentive for primary health professionals and non economic incentive measures, improve the grass-roots health personnel quantity quality, reduce the wastage rate; (3) strengthen financial the basic medical institutions infrastructure equipment, physical environment construction investment, the innovation of financial investment, actively improve the cost of reasonable fallback for performance; (4) Health Bureau to actively use the performance management balanced grassroots medical institutions of medical services and basic public health services, continue to strengthen the grassroots medical service function construction. Institutions actively expand the idea of the president. Improving medical services and basic public health service efficiency.

【學位授予單位】：南京醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R197.32

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