【作者】 余瑶；

【导师】 陶红兵； 方鹏骞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2008， 硕士

【摘要】 目的以病种医疗质量为单元,通过医疗费用的影响因素研究和专家咨询方法,结合病种临床路径的标准诊疗模式,找出影响病种医疗质量的关键因素和关键环节,确定病种医疗质量评价指标及其权重,并对指标评价标准进行研究,构建了病种医疗质量评价指标体系。本研究结合病种管理的特点,考虑医疗过程管理和医疗缺陷分析的需要建立了病种医疗质量评价指标体系,并提出相应的干预措施,为促进医院医疗质量的规范化管理提供了科学依据。方法1.文献研究法:查阅国内外关于临床路径应用现状、病种选择原则、医疗质量评价体系等相关研究方面的参考文献。2.德尔菲法:聘请临床医学专家和医院管理学专家共58名,通过问卷对专家进行咨询,确定病种医疗质量评价指标体系各指标及其权重。3.问卷调查法:利用调查问卷收集各样本医院两个病种共421例病例的诊治方案、医疗费用等数据。4.专题小组讨论:聘请临床医学专家和医院管理学专家15名,对病种医疗质量评价指标体系的应用和相应的干预措施进行讨论。5.统计学方法:利用Microsoft Office Excel2003建立数据库,进行专家咨询评价指标得分的计算。利用SPSS12.0分析软件对医疗费用的影响因素进行了描述性统计分析和多元线性回归分析。结果1.病种费用的关键影响因素分析通过国内外临床路径医疗质量管理的病种分析,提出了的病种选择原则。并通过单纯室间隔缺损修补术和单纯剖宫产术医疗费用影响因素分析对病种费用的关键影响因素进行了研究。单纯室间隔缺损修补术影响医疗费用的关键因素包括:输血费、术中耗材费、术中手术费、术中药费、术后药费、药品费用比、检查费用比、术中耗材费用比、术前抗生素用药天数、术前抗生素用药种类、术前待床天数。单纯剖宫产术医疗费用的关键影响因素包括:术前检查费、术中手术费、术中麻醉费、术中药费、术中处置费、术后检查费、术后诊疗护理费、药品费用比、检查费用比。因此病种医疗质量评价需要根据病种的特点和关键影响因素建立不同的评价指标以保证评价的科学性和合理性。2.病种医疗质量评价指标体系的建立单纯室间隔缺损修补术和单纯剖宫产术医疗质量评价指标体系包括4个一级指标,分别是医疗费用、疗程、诊疗合理性和病种医疗质量病人满意度。单纯室间隔缺损修补术医疗质量评价指标体系包括17个二级指标,分别是:术中药费、术中耗材费、术后诊疗护理费、术后药费、术后检查费、术前待床天数、药品费用比、检查费用比、术中耗材费用比、术后抗生素用药天数、特级护理小时数、血气分析次数、持续有创性血压监测小时数、医护人员对病人的服务态度、医护人员的服务过程、病种的诊治结果、健康教育的实施情况。单纯剖宫产术医疗质量评价指标体系包括15个二级指标,分别是:术前检查费、术中处置费、术后检查费、术后诊疗护理费、术后药费、术后住院天数、药品费用比、检查费用比、术中耗材费用比、术后抗生素用药天数、术后抗生素用药种类、医护人员对病人的服务态度、医护人员的服务过程、病种的诊治结果、健康教育的实施情况。3.基于病种医疗质量评价的干预策略研究(1)运用病种医疗质量评价指标体系对病种医疗质量实时控制:包括病种医疗质量过程的改进、持续性的改进和预防性的改进三个方面。(2)运用病种医疗质量评价分析医疗缺陷发生的原因并对其针对性改进。(3)运用病种医疗质量评价形成有效的激励和约束机制。结论1.病种医疗质量评价指标体系将医疗技术质量、服务质量、病人满意度和质量成本等全面质量特性包含在医疗质量管理范围之内,强调了医疗质量评价的系统性和完整性,有利于开展全面医疗质量管理。2.基于临床路径建立病种医疗质量评价指标体系依据每阶段病程的特点制定科学、详细的评价指标,并根据临床路径的标准值确定评价指标的标准值范围,强调了医疗质量的过程评价。3.基于临床路径的病种医疗质量评价指标体系强调不同病种诊疗过程和费用结构的特点,体现了病种的差异性。4.病种医疗质量评价指标体系为评价医院医疗质量提供了量化指标,为促进医院临床科室医疗工作的规范化和制度化提供了理论依据,有利于提高医疗质量的管理水平。5.病种医疗质量评价指标体系为医疗保险管理部门对医疗机构进行监督检查提供依据,顺应了医疗保险制度改革的发展趋势。更多还原

【Abstract】 ObjectiveThis study uses analysis of factors Affecting medical expenses and Delphi to identity the key factor and key links Affecting medical quality ,combining standards Diagnosis and treatment models of clinical pathway .Thus a assessment indicators system of medical quality of disease types can be formed.This system makes medical quality management directly, specifically implemented in the course of the Diagnosis and treatment.At the same time, it can Analysize the causes of medical defects and targeted to improve. The assessment indicators system of medical quality of disease types provided basis for standardization of medical practice of hospital departments and quantitative indicators for the evaluation of general hospitals.It become a tool for improving and evaluating the quality of hospitals.Method1.Documentary method: look up both domestic and international documents on the threory of clinical pathway, assessment indicators system of medical quality.2.Consult experts by questionnaire to identify the weights and standard system for assessment of medical quality.3.Questionnaire: questionnaire was used to collect that data of the indicators for assessment of medical quality.4.Consult experts by discussion to study on the intervention strategy.5.Statistics: Set up database with Microsoft Office Excel 2003 and further calculate SPSS12.0 was used for statistical analysis and especially linear regression analysis was performed.Results1.The analysis of key factors Affecting medical expenses of disease types.Set simple VSD and Cesarean section as examples, identify the key factoes affecting medical expenses of simple VSD and Cesarean section.The key factors affecting medical expenses of simple VSD are:blood transfusion fees, costs of supplies during surgery, surgery fees, drugs fees during surgery, drugs fees after surgery, drugs ration, inspections ration, ration of supplies during surgery, the days and types of antibiotic treatment before surgery, days prior to the surgery. The key factors affecting medical expenses of simple Cesarean section are:inspections fees before surgery, surgery fees, anesthesia fees, disposal fees during surgery, inspections fees after surgery, diagnosis and treatment fees after surgery ,drugs ration, inspections ration. Therefore, a assessment indicators system of medical quality of different disease types should include different key factors which reflects the characteristics of disease types what can ensure the scientific and rationality of assessment.2.Establishing a assessment indicators system of medical quality of disease types.The tier 1 indicators of assessment of simple VSD and Cesarean section are: medical expenses, days of hospitalization , reasonable treatment, patient satisfaction. The tier 2 indicators of assessment of simple VSD are: costs of supplies during surgery, drugs fees during surgery, drugs fees after surgery, drugs ration, inspections ration, ration of supplies during surgery, the days of antibiotic treatment after surgery, days prior to the surgery, diagnosis and treatment fees after surgery, hours of intensive care, numbers of blood gas analysis, hours of continued monitoring ambulatory blood pressure, attitude for medical service, service process, diagnosis and treatment efficacy, the implementation of health education. The tier 2 indicators of assessment of simple Cesarean section are: inspections fees after surgery, disposal fees during surgery, diagnosis and treatment fees after surgery ,drugs ration, inspections ration, drugs fees after surgery, days after surgery, ration of supplies during surgery, the days and types of antibiotic treatment after surgery, attitude for medical service, service process, diagnosis and treatment efficacy, the implementation of health education.3.Study on the intervention strategy.(1)Using the assessment indicators system of medical quality of disease types to play Real-time control, including process improving, continuous improvement and preventive improvement of medical qulity(.2)Analysizing the medical defects and tgrgeted improvement.(3)Form an effective incentive and restraint mechanismsConclusions1.The assessment indicators system of medical quality of disease types is comprehensive quality management including controls of medical technology quality, service quality, patient satisfaction and quality costs.2.The assessment indicators system of medical quality of disease types stressed the process control because the formation of it is based on the standards Diagnosis and treatment models of clinical pathway.3.The assessment indicators system of medical quality of disease types fouces on the characteristics of treatment processes and cost structures of different disease types which reflects the difference.4.The assessment indicators system of medical quality of disease types provided basis for standardization of medical practice of hospital departments and quantitative indicators for the evaluation of general hospitals.It become a tool for improving and evaluating the hospital management.5.The assessment indicators system of medical quality of disease types provides reference standards for supervision and inspection of the department of medical institutions which is a need for medical insurance reform.更多还原