农村贫困地区乡镇卫生院卫生服务质量改进策略和措施研究.doc

华中科技大学博士学位论文农村贫困地区乡镇卫生院卫生服务质量改进策略和措施研究姓名：张治国申请学位级别：博士专业：社会医学与卫生事业管理指导教师：张亮20080501 独创性声明本人郑重声明，本学位论文是本人在导师指导下进行的研究工作及取得的研究成果的总结。尽我所知，除文中已经标明引用的内容外，本论文不包含任何其他个人或集体已经发表或撰写过的研究成果。对本文的研究做出贡献的个人和集体，均已在文中以明确方式标明。本人完全意识到本人将承担本声明引起的一切法律后果。学位论文作者签名：日期：2008年 5月 24日学位论文版权使用授权书本学位论文作者完全了解学校有关保留、使用学位论文的规定，即：学校有权保留并向国家有关部门或机构送交论文的复印件和电子版，允许论文被查阅和借阅。本人授权华中科技大学可以将本学位论文的全部或部分内容编入有关数据库进行检索，可以采用影印、缩印或扫描等复制手段保存和汇编本学位论文。保密，在_年解密后适用本授权书。本论文属于不保密。（请在以上方框内打“”）学位论文作者签名：指导教师签名：日期：2008年 5月 24日日期：2008年 5月 24日 华中科技大学博士学位论文中文摘要研究目的医疗卫生领域向来以对质量的高要求作为其显著的特征之一，卫生服务质量问题已经列入各级政府的重要议事日程。乡镇卫生院是农村三级医疗卫生服务网络的枢纽，在农村卫生服务工作中占据重要的地位。在农村贫困地区，能否持续改进乡镇卫生院卫生服务质量更直接影响到农民卫生服务需求的满足程度，也直接影响着广大农民的健康水平。本研究试图在卫生项目/卫生支持性项目 B1领域近十年来对农村贫困地区乡镇卫生院卫生服务质量改进干预的实践基础上，结合国内外相关文献的分析，从理论和实践方面系统总结农村贫困地区乡镇卫生院卫生服务质量改进的策略和措施，分析其实施效果以及相应的影响因素，寻找适宜的策略和措施，为今后各级政府改进农村贫困地区乡镇卫生院卫生服务质量提供借鉴依据。研究方法（1）文献查阅和内容分析法。通过检索工具获取了国内外相关研究资料，同时还对120篇国内有关农村贫困地区乡镇卫生院卫生服务质量问题表现的相关文献资料运用内容分析的方法进行了文献计量统计。（2）专家咨询法。通过专家咨询确定了现场调查的问卷和访谈提纲，并对调查中发现的改进策略和措施实施效果及其影响因素进行了专家咨询。（3）选题小组讨论。使用选题小组讨论分别对农村贫困地区乡镇卫生院合理用药的影响因素、临床诊疗规范实施效果的影响因素和使质量改进工作真正落实的有效做法3个方面进行调查。（4）统计描述和统计推断分析方法。使用算术平均数、频数、率等进行了相关的描述性统计。使用卡方检验、Cochr an- Ar mi t age趋势检验、Kendal l协同系数检验等统计推断方法进行了相应的假设检验。使用结构方程模型对反馈的卫生服务质量评价数据拟合了相应的模型。（ 5）运筹学中的鱼刺图方法。借鉴运筹学中的鱼刺图分析方法，对相应卫生服务质量改进策略和措施的影响因素进行了系统梳理和总结。1 华中科技大学博士学位论文研究结果通过对农村贫困地区乡镇卫生院卫生服务质量改进的策略和措施以及相应的影响因素总结分析，得出了如下结果：（1）至今尚无统一的卫生服务质量定义，要改进农村贫困地区乡镇卫生院卫生服务质量，今后需进一步明确卫生服务质量评价和改进的概念框架。（2）除硬件等结构质量问题外，目前农村贫困地区乡镇卫生院卫生服务质量存在的主要问题突出表现在过程质量方面，包括：医务人员素质较低导致诊疗水平低下，尤其是缺乏基本的诊断和治疗规范，医疗文书书写也缺乏规范；药物使用不合理，突出表现为抗菌药、激素和静脉输液的不合理使用上；公共卫生服务开展不足等。（3）基本药物和合理用药策略的具体措施可以从措施产生的方向分为机构内部和机构外部干预措施两个方面，也可从措施作用的方向分为能力、压力和动力三类。具体包括：成立领导组织；开发相关知识手册；对医务人员保证持续性的培训和宣传教育；将合理用药制度化；建立有效的外部评价和督导机制，不断根据实际情况调整评价和督导的重点；与合作医疗和医疗救助等相关制度相结合，形成合力；充分调动乡镇卫生院自身的自主性和创造性，推进基本药物与合理用药策略。相应的影响因素可以归纳为以下方面：地区经济因素、医务人员因素、患方因素、医疗机构因素、宏观环境因素、药品供应因素、“以药补医”的补偿机制因素、药物信息因素、医学教育因素和不可控因素等。（4）临床诊疗规范策略的具体措施包括：成立领导组织；制定和推行临床诊疗规范；进行各类专业培训；规范医疗文书书写；实施临床诊疗督导；严格乡镇卫生院考评制度；开展技术交流；开展多方监督，并建立信息反馈机制。影响医务人员临床诊疗规范行为的前 5个因素分别是医务人员的知识水平、对临床诊疗规范相关知识的培训力度、医务人员的诊疗习惯、是否将医务人员的诊疗质量与绩效考核相挂钩、患者的健康意识。（5）农村贫困地区乡镇卫生院卫生服务质量改进的反馈评价结果表明：普遍反映最好的质量方面包括平均住院费用、住院患者治愈好转率、居民满意度。普遍反映较好的质量方面包括健康教育可及性、五苗及时接种率、孕产妇系统管理率、平均门诊处方药品费用、诊疗合理率、医疗安全性、护士交接班规范性、法定传染病漏报率、门诊处方基本药物2 华中科技大学博士学位论文使用百分比、门诊抗菌药2联及以上联用处方百分比、出入院诊断符合率、设施完好性、质量评价规范性、质量改进全面性、药品收入占业务收入百分比。普遍反映一般的质量方面包括门诊激素处方百分比、人员合理性、相对市场份额。普遍反映较差的质量方面包括选择本院住院分娩百分比、 0- 7岁儿童体检率、门诊静脉输液处方百分比、医疗文书书写（特别是留观登记书写）。结构方程模型表明农村贫困地区乡镇卫生院卫生服务质量总体影响因素，从大到小依次是合理用药、质量改进规范性、诊疗质量、公共卫生服务质量、设施完好程度、医疗文书书写、人员合理程度。研究结论通过本研究得出如下结论：（1）卫生服务质量评价和改进应该从满足特定医学标准的程度和满足居民需要的程度两个方面来进行，但目前仍以衡量满足特定医学标准的程度为主。（2）世界各国的卫生服务质量评价及相应的改进重点不尽相同，就是同一国家在不同的发展阶段其卫生服务质量的内涵也不同。针对我国农村贫困地区乡镇卫生院的现实情况，目前在不断改进硬件等结构质量的基础上，主要应从促进乡镇卫生院基本药物应用和合理用药，推行基本的诊疗规范等方面入手。（3）所有干预策略和措施的最终成功均是 PDCA循环的结果，必须根据实际情况不断改进干预措施和重点。（4）农村中心乡镇卫生院卫生服务质量评价指南目前可有效评价农村贫困地区乡镇卫生院卫生服务质量，并对其质量改进起到导向作用。政策建议（1）除了对患者加强用药知识的宣教之外，改进农村贫困地区乡镇卫生院的药物使用状况，目前更多应该从医务人员角度入手。有两类措施对推行基本药物和合理用药比较重要，一是通过制度设计来纠正乡镇卫生院和医务人员受经济利益的驱使而不合理使用药物，另一方面，因为用药行为的改变不是一个一蹴而就的过程，因此必须持续不断地加强对医务人员基本药物和合理用药知识的培训，纠正其不合理的诊疗习惯，提高医务人员的知识水平。（ 2）目前非常有必要就农村贫困地区的临床诊疗规范进行干预，关键在于建立国家级的乡镇卫生院基本诊断和治疗规范，也包括医疗3 华中科技大学博士学位论文文书书写规范。大范围推广时首先需要针对各地实际制定相应的常见病、多发病临床诊疗规范，在推行过程中可采取由少到多，由浅到深的方式进行；同时采取适合农村贫困地区教学的方式，推行过程中尽量多采取案例、实践等更适合成人教学的形式，提高干预措施的干预效果。（3）设计的改进策略和措施均应该系统思考，发挥合力的作用。( 4)在农村卫生系统的改革过程中，一定要充分发挥基层卫生部门的制度创新能力。（5）针对基层卫生服务提供者，所有改革干预措施均应围绕能力、动力和压力这“三力”角度加以综合设计。研究的创新与不足之处1.研究的创新性本研究立足于卫生项目/卫生支持性项目 B1领域近十年来对农村贫困地区乡镇卫生院卫生服务质量改进的实践工作，结合国内外相关文献的分析，从理论和实践方面较为系统地总结了农村贫困地区乡镇卫生院卫生服务质量特别是基本药物与合理用药和临床诊疗规范两个核心方面的改进策略和措施，分析策略和措施实施效果以及相应的影响因素，找出了适宜的策略和措施，为今后各级政府改进农村贫困地区乡镇卫生院卫生服务质量提供了借鉴依据。本研究还运用结构方程模型，构建了农村贫困地区乡镇卫生院卫生服务质量改进的理论模型，找出了农村贫困地区乡镇卫生院卫生服务质量改进的关键切入点，也为政府和学者研究农村贫困地区乡镇卫生院卫生服务质量的改进提供了相应参考。2.研究的不足农村贫困地区乡镇卫生院的卫生服务质量涵盖面非常广泛，在博士阶段不可能穷尽其所有内容和所有的核心改进策略和措施，同时卫生服务质量改进也是一个PDCA循环的过程，其核心干预点和相应的改进策略和措施也会随着我国农村贫困地区乡镇卫生院卫生服务质量的变化而变化。囿于时间、精力和经费的限制，本研究主要立足于农村中心乡镇卫生院卫生服务质量评价指南所评价的内容和两大核心干预策略所涉及的内容展开，虽然可以研究得相对较为详细和深入，但可能会漏掉了农村贫困地区乡镇卫生院卫生服务质量中的一些关键内容，如非技术服务中的服务态度等，虽然4 华中科技大学博士学位论文居民满意度中有所涉及，但仍然有可能关注不够全面。因此，最好先通过文献回顾和专家咨询建立一个卫生服务质量评价和改进的概念模型，建立农村贫困地区乡镇卫生院卫生服务质量核心概念的框架，明确其内涵，以使研究成果在今后更长时间内发挥作用。在后续研究中，这是应该努力解决的一个关键问题。另外，本研究主要针对了我国中西部农村贫困地区的中心乡镇卫生院，对于普通乡镇卫生院和更大范围内的乡镇卫生院卫生服务质量特征和改进策略没有进行探讨，这也是需要今后不断改进和关注的一个研究不足之处。关键词：农村；贫困地区；乡镇卫生院；卫生服务质量；改进；策略；措施5 华中科技大学博士学位论文ABSTRACTObjectives：One of its notable features, the high quality has always been requested inmedical and health fields，and the quality problems of health service have also beenincluded in the agenda of all levels of governments. Township health centers, as the knob inthe third-class networks, play an important role in the rural health service. In rural povertyareas, health service quality of township health centers, whether or not been sustainablelyimproved, directly impacts on how to meet farmers health services needs of degree, andalso directly affects the health level of the majority of farmers. Over the past 10 years,intervention strategies have been performed on the health services quality improvement oftownship health centers in rural poverty areas, which was supported by B1 area of theeighth projects /support projects in the health. On the basis of these practice measurementsand analysis of domestic and foreign relative literatures, this study will attempt tosystematically summary the improvement strategies and tactics of health services quality inrural township health centers from the theoretical and practical points, and analyze theresults of implementation and the influential factors. These will provide a reference for alllevels of governments to improve the health service quality of township health centers inrural poverty areas in the future.Methods：(1)Literatures and content analysis: The relevant domestic and foreignresearch data were obtained by searching tools. 120 documents, about the problems ofhealth services quality of township health centers in rural poverty areas, was statisticmeasured by the use of content analysis. (2)Experts consultation: The questionnaires for thespot survey and interviews outline were defined by experts consultation.Theimplementation strategies, tactics and influential factors, which were found during survey,were also consulted the advice of experts. (3)Nominal group discussion: Nominal groupdiscussion were applied for the influential factors of rational use of drugs, the influentialfactors of the implementation effect of standardized clinical treatment, and the effective6 华中科技大学博士学位论文practice to improve the quality of township health centers in rural poverty areas.(4)Statistical description and statistical inference: The arithmetic average, frequency andrate were used for the relevant descriptive statistics. The hypothesis tests, such as thechi-square test, Cochran-Armitage trend test, Kendalls coefficient of concordance test wereused for statistical inference. The feedback data on the health service quality evaluationwere fitted the corresponding model by structural equation model. (5)The method of figurefishbone in operation research: The influential factors of improvement strategies and tacticson the health service quality were systemically sorted out and summed up by the method offigure fishbone in operation research.Results：The results were achieved by analysis of strategies and tactics of improvementof health service quality of township health centers and its relevant influentialfactors:(1)There has no uniform definition of health service quality up to the present. Theconceptual framework of assessment and improvement of health service quality oftownship health centers must be clarified in rural poverty areas in future. (2)Besides thestructure quality problems such as hardwares, the prominent problems were in the processquality to the present township health centers in rural poverty areas, including the lowertrained personnel which caused lower diagnosis and treatment level especially lacking ofbasic diagnosis and treatment standards and the medical records writing standards, theabuse of drugs especially in antibacterias, hormone and vein infusion, the insufficiency ofpublic health service, and so on. (3)The essential drugs and rational use of drugs strategyand tactics could be devided two parts which were internal and external intervention tacticsby its derivation aspect and three parts which were capability, pression and impetus by itseffect aspect. These included:established leader organization;developed relativeknowledge handbooks;continuous education and propagation of medical personnels;involve the rational use of drug into regulation;set up effective external assessment andmonitor mechanism and adjusted the key point of assessment and monitor according to thesituation;cooperation with the cooperative medical schemes and medical finance aid to7 华中科技大学博士学位论文form composition of forces;fully mobilized the independence and creations of townshiphealth centers to boost essential drugs and rational use of drugs strategy. The correspondinginfluential factors included: the economy of areas, medical stuff, patient, medicalorganization, macro-circumstance, drug supply, the mechanism of “medical reimbursementby drugs”, medicine information, medical education and non-controlled factors, and so on.(4)The clinical treatment standard strategy and tactics included:established leaderorganization;constituted and implemented the clinical treatment;educated by variousspecialty;standardized medical records writing;monitored the clinical treatment;rigorously implement check system of township health centers;technical communication;multiple monitoring and information feedback. The first five influential factors ofclinical treatment strategy included knowledge level of medical stuff, educational level ofclinical treatment,treatment habit of medical stuff, whether or not putting the treatmentquality and performance assessment together, patients health consciousness.(5)Theassessment results of the feedback of improvement of township health centers in ruralpoverty areas showed:the general best qualtiy aspects included per inpatient cost,improved cure rates, satisfaction of residents;the general better qualtiy aspects includedaccessibility of health education, timely vaccination rate of 5 vaccines, Maternalsystematical management rate, drug cost per outpatient prescription, reasonable treatmentrate, safety of treatment, norm of nurse shift, Omitting rate of the statutory infectiousdiseases, percentage of essential drugs in outpatient prescription, 2 and more antibacterialdrugs use rate in outpatient prescription, meeting rate of inpatient and outpatient diagnosis,intact rate of facilities, norm of quality assessment, full-scaled rate of quality improvement,drug income percent in total income.the general common qualtiy aspects includedhormone use percent in outpatient, rationality of personnel, relative market share.thegeneral bad qualtiy aspects included delivery rate in the township health center, 0-7children medical examination rate, vein infusion percent in outpatient, medical recordwriting(especial retained record writing).the SEM showed the descending sequential8 华中科技大学博士学位论文influential factors were rational use of drugs, norm of quality improvement, treatmentquality, quality of public health service, intact rate of facilities, medical record writing andrationality of personnel.Conclusions：The conclusion of this study are:(1)The assessment and improvement ofhealth service quality should meet with medical criterion and satisfaction of residents. Butnow it must focus on medical criterion.(2)The core point of the assessment andimprovement of health service quality is different in different countries even in differentdevelopment stage in one country.According to township health centers of rural povertyareas, based on continuous improvement of structure quality such as hardwares, essentialdrugs and rational use of drugs and basic treatment standards should be put to the firstnow.(3)The final success of all strategies and tactics is based on PDCA cycle. Theintervention tactics and emphases should be continuously adjusted according to situation.(4)“The guideline of assessment of health service quality in central township health centers”could effectively assess health service quality and direct the improvement.Suggestions：(1)Besides the education of drug for patients, medical stuff should bepaid more attention to improve drug use of township health centers in rural poverty areasnow. There are two important tactics. One is mechnism design to correct abuse of drugs byeconomy factors. The other is continuous education of essential drugs and rational use ofdrugs, which can correct the wrong habit of abuse of drugs and to impove the knowledge.(2)It is necessary to intervene the clinical treatment standards. The key issue is to establishnational basic diagnosis and treatment standards of township health centers includingmedical record writing standard. To apply widely, firstly the treatment standards of familiarand excessive diseases should be defined according to different situation. The process canfollow from a little to many, from facile to deep method and use appropriate educationmethod accustomed to rural poverty areas. To improve effect of intervention tactics, adultstudy such as case study and practice should be more accepted.(3)The improvementstrategies and tactics should be systematicall designed to form the composition of9 华中科技大学博士学位论文forces.(4)The grassroot health organization should exert mechanism innovation in healthreform of rural health system.(5)All intervention should focus on “three forces”-capability,impetus and pression for the grassroot health supplier.Innovations and drawbacks of this study：1. Innovations of this studyIn this study, based on the practical work of health services quality improvement oftownship health centers in rural poverty areas over the past 10 years, which was supportedby B1 area of the eighth projects / support projects, and combined with the domestic andforeign literatures analysis, the improvement strategies and tactics in health service qualitywere systematically summed up from both theory and practice points, especially in bothessential drugs and rational use of drugs, and regulation of clinical treatment of townshiphealth centers in the rural poverty areas. At the same time, the influential factors and effectsof implement strategies and tactics were also analyzed. The appropriate strategies andtactics were found. These could provide the reference for government at all levels toimprove the health services quality of township health centers in rural poverty areas.This study also constructed the theoretical models for improvement of health servicesquality of township health centers in rural poverty areas by the methods of structuralequation model. The key entry point for quality improvement was found and also wasprovided for the government and academics as a reference.2. Drawbacks of this studyThe health service quality of township health centers in rural poverty areas contains thevery extensive contents. Therefore, the whole contents and all core strategies and tacticscannot be covered during the stage of my doctor degree. While improving the quality ofhealth services is the process of PDCA cycle, the core of intervention point and thecorresponding strategies and tactics will also vary with the improvement of health servicesquality of township health centers in rural poverty areas of China. Limited time, energy and10 华中科技大学博士学位论文financial constraints, this study was mainly based on “evaluation guide of health servicesquality of the rural township health centers”. Although these contents were given arelatively detailed and deeply study, some key elements, such as service attitudes ofnon-technical services, may be left out. Only the satisfaction of the residents on this surveywas involved. Therefore, the best way was to establish the conceptual framework of theassessment and improvement on health service quality by literature review and expertadvice, and to construct the framework of core concept about health service quality oftownship health centers in rural poverty areas, and to identify their contents. In the end,these research results would play a role in the future longer time. In follow-up study, thisshould be a key issue to be resolved.In addition, this study only addressed the central township health centers in the centraland western Chinas