【作者】 张艳；

【导师】 李永奎；

【作者基本信息】 同济大学 ， 管理科学与工程， 2022， 博士

【摘要】 我国医院服务供求矛盾十分突出,这种矛盾不仅是源于资源相对不足的服务数量供求矛盾,更突出的是服务质量的供求矛盾,当前的医院服务水平无法满足人民日益增长的对高质量服务的迫切需求。医院建筑规划设计和服务体系设计的不合理、医院建设和运营的粗放式管理等多种因素造成了患者就诊体验差、满意度差。在供需两端矛盾夹持的现实情况下,提升医院服务绩效是当前我国医院建设与服务运营管理需要解决的重要现实问题。本文以医院服务系统为研究对象,立足实践需求,遵循“问题导向”的研究思想,综合运用管理科学、工程管理、建筑行为学、信息科学等学科理论以及运筹学、计算实验、智能优化算法、BIM等方法及技术工具,开展跨学科研究。医院服务是在一定的集聚空间和技术条件下开展的专业行为。医院空间、医疗流程以及用户行为等诸多要素相互作用耦合,共同构成一个复杂的医院服务系统。其中,医院建筑空间是承载医院服务的物理载体,医疗流程是医院提供医疗服务及患者就诊的程序规范。从服务过程视角出发按群体分析用户行为,患者就诊过程包含三种主要的用户行为:医疗行为,即患者按照医疗流程执行的各种医疗活动;移动行为,即执行活动过程中患者在空间中的移动往来;以及寻路行为,即患者在复杂的医院空间中识别位置并找到路线的过程。作为服务提供方的医院,则依托于医疗流程的组织和各类医疗资源的支持开展其服务行为。医院服务绩效提升本质上是对上述用户行为的更好“塑造”。本研究以复杂系统理论为基础,创新性地关注医院空间、医疗流程与用户行为之间的耦合关系,并基于此从行为导向的视角出发,选取四个典型情景问题开展医院空间和医疗流程的优化决策研究,以实现医院服务绩效的提升。本文的研究内容主要为:(1)空间与流程耦合及其对用户行为的作用。基于本体论思维,研究构建了空间-流程-行为(SPB)本体关系模型,通过定义和阐释本体关系模型中各元组及其类属性,为我们理解医院空间和医疗流程交互耦合并最终作用于各类用户行为的过程提供了深刻的理论阐释。同时,本体关系模型中类属性的定义也是后续情景问题研究中对服务系统仿真建模的数据结构基础。(2)医疗行为导向的空间布局设计决策。研究从改善患者就诊过程中医疗行为的视角进行空间布局设计备择方案的评估决策。研究定义了一个基于系统仿真方法的空间布局设计决策框架,通过应用离散事件仿真方法(DES)模拟医院服务运营及患者的就诊过程,定量评估不同备择方案对患者就诊过程医疗行为的绩效表现。研究借助一个门诊骨科的布局设计决策案例验证了拟议框架及方法的可行性,同时借助案例详细阐述了医院服务空间系统、流程系统及行为系统的仿真建模程序。(3)移动行为导向的空间布局设计诊断。研究旨在考量空间布局设计是否与流程相互适配以保证患者就诊过程中在建筑空间内往来移动的便利性。研究构建了一个空间布局设计诊断框架,从网络的视角分析布局设计“瓶颈”识别。首先借助开发的数据挖掘程序从患者就诊日志中自动化提取和处理活动信息最终形成患者就诊活动网络;其次借助开发的Revit平台插件,自动化提取BIM模型实体信息,应用改进的最短路径算法计算就诊活动网络中活动点对间路径的相关属性值;最后构建了一个布局设计诊断分析模型,基于包含路径属性信息的移动路径网络对布局设计进行瓶颈点识别和原因分析。框架和模型由选取的门诊综合楼案例得到了验证。(4)寻路行为导向的空间标识布局设计优化。研究定义了一个空间标识布局设计框架。BIM和行人仿真方法被用来预测在理想寻路情景下前往不同目的地的用户的空间使用分布。基于此分布,研究构建了数学优化模型对空间标识的覆盖范围进行优化。优化模型的核心逻辑是提高空间使用分布(即用户对寻路信息的需求)和空间标识覆盖范围(即空间标识所提供的导航信息)之间的匹配程度。空间标识覆盖范围由表达用户与空间标识感知交互关系的解析模型获得。研究选取了一个门诊大厅开展案例研究。仿真模型和一个基于VR的导航寻路实验验证了优化后的空间标识布局环境中用户寻路时间更短,且满意度更高。(5)服务行为导向的医疗流程资源配置决策。研究定义了一个资源配置决策框架,纳入了对决策风格异质性的考虑,其核心是一个混合决策模型。离散事件仿真方法(DES)被用于刻画患者就诊行为活动,估计资源配置备择方案在不同运行情景下的服务绩效表现。一个整合了分区多目标风险法(PMRM)和敏感性指数方法(USIM)的数学模型被用于对比资源配置备择方案在不确定性条件下绩效的鲁棒性表现。一个消化科的实际案例项目支持了所提出的框架和模型方法在帮助资源配置决策方面是有效的。本研究围绕医院服务系统要素耦合和基于空间与流程优化的绩效提升开展了跨学科交叉研究,在理论与方法上具有前瞻性和创新性,同时又注重研究成果的实用性。研究对于丰富和完善复杂运营管理及医疗服务等理论,以及提升我国医疗服务效能、服务品质和安全水平,适应快速变化的复杂新情境,提高医患满意度,助推“健康中国战略”的实现具有重要现实意义。更多还原

【Abstract】 The contradictions between supply and demand of hospital services in China are very prominent.This is not only a contradiction in the service quantity stemming from the relative lack of resources,but more prominently in the service quality.The existing level of hospital services cannot satisfy the people’s growing urgent demand for highquality services.The unreasonable design of hospital building and service system,the sloppy management of hospital construction and operation,and many other factors have caused poor patient experience and satisfaction.Under the reality of contradictions between supply and demand,improving hospital service performance is an important practical problem that needs to be solved in the current hospital construction and service operation management.This paper takes hospital service system as the research object,bases on practical needs and "problem-oriented" research ideology,and makes comprehensive application of management science,engineering management,building behavior,information science and other discipline theories,as well as operation research,computational experiments,intelligent optimization algorithms,BIM and other methods and technical tools to carry out interdisciplinary research.Hospital service is a professional activity carried out in a certain set of spatial and technological conditions.Hospital space,medical processes and other mutually coupled elements together constitute a complex hospital service system.Hospital space functions as the physical foundation for hospital services,while medical processes establish the procedural guidelines for both hospitals in delivering medical care and patients in seeking treatment.By analyzing user behaviors through a service process lens,we identify three primary behavioral patterns exhibited by patients during their hospital visits: medical behaviors,encompassing the various medical activities patients undertake in accordance with established processes;mobility behaviors,referring to patients’ movements and displacements within the hospital environment during their visit;and wayfinding behaviors,which involve patients navigating and locating specific areas within the intricate hospital layout.Hospitals,as the service providers,rely on the well-orchestrated medical processes and the availability of diverse medical resources to execute their service offerings.Fundamentally,enhancing hospital service performance is contingent on optimizing these user behaviors.Leveraging complex system theory,this study innovatively examines the interconnectedness between hospital space,medical processes,and user behaviors.Therefore,this paper conducts specific research on four typical scenario problems in the context of medical behavior,mobility behavior,wayfinding behavior,and service behavior orientation.The main research of this paper is as follows.(1)Spatial-process coupling and its effect on user behavior.Based on ontological thinking,an ontological model of space-process-behavior(SPB)is constructed,and the definition of tuple class attributes and the interpretation of association relationships in the SPB ontological model provide an insightful epistemological explanation for understanding the process of space-process interaction coupling and its ultimate effect on various user behaviors.At the same time,the class attribute definitions of the ontology relationship model are also the data structure basis for the simulation modeling of service systems in the subsequent scenario problem studies.(2)Medical behavior-oriented spatial layout design decisions.The study evaluates spatial layout alternatives from the perspective of improving medical behaviors during patient visits.The study defines a spatial layout decision-making framework based on a system simulation approach,and quantitatively evaluates the performance of different alternatives on medical behavior during patient visits by applying a discrete event simulation(DES)approach to simulate hospital service operations and patient visits.The study validates the feasibility of the proposed framework and methodology with a case study of an outpatient orthopedic department’s layout decision,and also elaborates the simulation modeling procedures of the hospital service spatial system,process system and behavioral system.(3)Mobility behavior-oriented space layout design diagnosis.The study aims to consider whether the space layout is compatible with the process to ensure the ease of movement of patients within the building space during the consultation process.A spatial layout diagnosis framework was developed to analyze the identification of layout design "bottlenecks" from a network perspective.Firstly,a data mining program is developed to automatically extract and process activity information from patient visit logs to form a patient visit activity network;secondly,a Revit platform plug-in is developed to automatically extract BIM model entity information and apply an improved shortest path algorithm to calculate the relevant attribute values of paths between pairs of activity points in the visit activity network;finally,a layout design diagnostic analysis model is constructed.The bottleneck identification and cause analysis of the layout is based on the movement path network containing the path attribute information.The framework and model are validated by the selected case of an outpatient complex building.(4)Wayfinding behavior-oriented spatial signage layout optimization.A spatial signage layout design framework is defined and BIM and pedestrian simulation methods are used to predict the spatial usage distribution of users traveling to different destinations in an ideal wayfinding scenario.A mathematical optimization model optimizes the visibility of spatial signage based on this distribution.The core logic of the optimization model is to improve the match between the spatial usage distribution(i.e.,the user’s need for wayfinding information)and the spatial sign coverage area(i.e.,the navigation information provided by the spatial sign).The spatial sign coverage is obtained from a parsing model that expresses the perceptual interaction between users and spatial signs.An outpatient lobby was selected for the case study.Simulation models and a VR-based navigational pathfinding experiment verified shorter user pathfinding times and higher user satisfaction in the optimized layout.(5)Service behavior-oriented resource allocation decisions for healthcare processes.The study defines a resource allocation decision framework that incorporates consideration of decision style heterogeneity,with a hybrid decision model at its core.Discrete-event simulation methods were used to characterize the behavioral activities of patient visits and to estimate the service performance of resource allocation alternatives under different operational scenarios.A mathematical model integrating the partitioned multi-objective risk method(PMRM)and the sensitivity index method(USIM)was used to compare the robust performance of resourcing alternatives under uncertainty.A real-world case project in gastroenterology supports the effectiveness of the proposed framework and modeling approach in aiding resource allocation decisions.This study is an interdisciplinary study on the coupling of hospital service system elements and performance improvement,which is forward-looking and innovative in theory and methodology,while focusing on the practicality of the research results.The research is important for enriching and improving the theories of complex operation management and healthcare services,as well as improving the effectiveness,service quality and safety of healthcare services in China,adapting to the new complex situation of rapid changes,improving the satisfaction of doctors and patients,and promoting the realization of the "Health China Strategy".更多还原