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
|
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Ⅷ项目/卫生Ⅷ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、Cochran-Armitage趋势检验、Kendall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。
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:①成立领导组织;②开发相关知识手册;③对医务人员保证持续性的培训和宣传教育;④将合理用药制度化;⑤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;⑥与合作医疗和医疗救助等相关制度相结合,形成合力;⑦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:①成立领导组织;②制定和推行《临床诊疗规范》;③进行各类专业培训;④规范医疗文书书写;⑤实施临床诊疗督导;⑥严格乡镇卫生院考评制度;⑦开展技术交流;⑧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:①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。②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。③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。④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)。⑤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Ⅷ项目/卫生Ⅷ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。
Objectives:One of its notable features, the high quality has always been requested in medical and health fields,and the quality problems of health service have also been included in the agenda of all levels of governments. Township health centers, as the knob in the third-class networks, play an important role in the rural health service. In rural poverty areas, health service quality of township health centers, whether or not been sustainablely improved, directly impacts on how to meet farmers’health services needs of degree, and also 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 of township health centers in rural poverty areas, which was supported by B1 area of the eighth projects /support projects in the health. On the basis of these practice measurements and analysis of domestic and foreign relative literatures, this study will attempt to systematically summary the improvement strategies and tactics of health services quality in rural township health centers from the theoretical and practical points, and analyze the results of implementation and the influential factors. These will provide a reference for all levels of governments to improve the health service quality of township health centers in rural poverty areas in the future.
Methods:(1)Literatures and content analysis: The relevant domestic and foreign research data were obtained by searching tools. 120 documents, about the problems of health services quality of township health centers in rural poverty areas, was statistic measured by the use of content analysis. (2)Experts consultation: The questionnaires for the spot survey and interviews outline were defined by experts consultation.The implementation strategies, tactics and influential factors, which were found during survey, were also consulted the advice of experts. (3)Nominal group discussion: Nominal group discussion were applied for the influential factors of rational use of drugs, the influential factors of the implementation effect of standardized clinical treatment, and the effective practice to improve the quality of township health centers in rural poverty areas. (4)Statistical description and statistical inference: The arithmetic average, frequency and rate were used for the relevant descriptive statistics. The hypothesis tests, such as the chi-square test, Cochran-Armitage trend test, Kendall’s coefficient of concordance test were used for statistical inference. The feedback data on the health service quality evaluation were fitted the corresponding model by structural equation model. (5)The method of figure fishbone in operation research: The influential factors of improvement strategies and tactics on the health service quality were systemically sorted out and summed up by the method of figure fishbone in operation research.
Results:The results were achieved by analysis of strategies and tactics of improvement of health service quality of township health centers and its relevant influential factors:(1)There has no uniform definition of health service quality up to the present. The conceptual framework of assessment and improvement of health service quality of township health centers must be clarified in rural poverty areas in future. (2)Besides the structure quality problems such as hardwares, the prominent problems were in the process quality to the present township health centers in rural poverty areas, including the lower trained personnel which caused lower diagnosis and treatment level especially lacking of basic diagnosis and treatment standards and the medical records writing standards, the abuse of drugs especially in antibacterias, hormone and vein infusion, the insufficiency of public health service, and so on. (3)The essential drugs and rational use of drugs strategy and tactics could be devided two parts which were internal and external intervention tactics by its derivation aspect and three parts which were capability, pression and impetus by its effect aspect. These included:①established leader organization;②developed relative knowledge handbooks;③continuous education and propagation of medical personnels;④involve the rational use of drug into regulation;⑤set up effective external assessment and monitor mechanism and adjusted the key point of assessment and monitor according to the situation;⑥cooperation with the cooperative medical schemes and medical finance aid to form composition of forces;⑦fully mobilized the independence and creations of township health centers to boost essential drugs and rational use of drugs strategy. The corresponding influential factors included: the economy of areas, medical stuff, patient, medical organization, macro-circumstance, drug supply, the mechanism of“medical reimbursement by drugs”, medicine information, medical education and non-controlled factors, and so on. (4)The clinical treatment standard strategy and tactics included:①established leader organization;②constituted and implemented the clinical treatment;③educated by various specialty;④standardized medical records writing;⑤monitored the clinical treatment;⑥rigorously implement check system of township health centers;⑦technical communication;⑧multiple monitoring and information feedback. The first five influential factors of clinical treatment strategy included knowledge level of medical stuff, educational level of clinical treatment,treatment habit of medical stuff, whether or not putting the treatment quality and performance assessment together, patient’s health consciousness.(5)The assessment results of the feedback of improvement of township health centers in rural poverty areas showed:①the general best qualtiy aspects included per inpatient cost, improved cure rates, satisfaction of residents;②the general better qualtiy aspects included accessibility of health education, timely vaccination rate of 5 vaccines, Maternal systematical management rate, drug cost per outpatient prescription, reasonable treatment rate, safety of treatment, norm of nurse shift, Omitting rate of the statutory infectious diseases, percentage of essential drugs in outpatient prescription, 2 and more antibacterial drugs 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.③the general common qualtiy aspects included hormone use percent in outpatient, rationality of personnel, relative market share.④the general bad qualtiy aspects included delivery rate in the township health center, 0-7 children medical examination rate, vein infusion percent in outpatient, medical record writing(especial retained record writing).⑤the SEM showed the descending sequential influential factors were rational use of drugs, norm of quality improvement, treatment quality, quality of public health service, intact rate of facilities, medical record writing and rationality of personnel.
Conclusions:The conclusion of this study are:(1)The assessment and improvement of health service quality should meet with medical criterion and satisfaction of residents. But now it must focus on medical criterion.(2)The core point of the assessment and improvement of health service quality is different in different countries even in different development stage in one country.According to township health centers of rural poverty areas, based on continuous improvement of structure quality such as hardwares, essential drugs and rational use of drugs and basic treatment standards should be put to the first now.(3)The final success of all strategies and tactics is based on PDCA cycle. The intervention 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 be paid more attention to improve drug use of township health centers in rural poverty areas now. There are two important tactics. One is mechnism design to correct abuse of drugs by economy factors. The other is continuous education of essential drugs and rational use of drugs, 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 establish national basic diagnosis and treatment standards of township health centers including medical record writing standard. To apply widely, firstly the treatment standards of familiar and excessive diseases should be defined according to different situation. The process can follow from a little to many, from facile to deep method and use appropriate education method accustomed to rural poverty areas. To improve effect of intervention tactics, adult study such as case study and practice should be more accepted.(3)The improvement strategies and tactics should be systematicall designed to form the composition of forces.(4)The grassroot health organization should exert mechanism innovation in health reform 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 study
In this study, based on the practical work of health services quality improvement of township health centers in rural poverty areas over the past 10 years, which was supported by B1 area of the eighth projects / support projects, and combined with the domestic and foreign literatures analysis, the improvement strategies and tactics in health service quality were systematically summed up from both theory and practice points, especially in both essential drugs and rational use of drugs, and regulation of clinical treatment of township health centers in the rural poverty areas. At the same time, the influential factors and effects of implement strategies and tactics were also analyzed. The appropriate strategies and tactics were found. These could provide the reference for government at all levels to improve the health services quality of township health centers in rural poverty areas. This study also constructed the theoretical models for improvement of health services quality of township health centers in rural poverty areas by the methods of structural equation model. The key entry point for quality improvement was found and also was provided for the government and academics as a reference.
2. Drawbacks of this study
The health service quality of township health centers in rural poverty areas contains the very extensive contents. Therefore, the whole contents and all core strategies and tactics cannot be covered during the stage of my doctor degree. While improving the quality of health services is the process of PDCA cycle, the core of intervention point and the corresponding strategies and tactics will also vary with the improvement of health services quality of township health centers in rural poverty areas of China. Limited time, energy and financial constraints, this study was mainly based on“evaluation guide of health services quality of the rural township health centers”. Although these contents were given a relatively detailed and deeply study, some key elements, such as service attitudes of non-technical services, may be left out. Only the satisfaction of the residents on this survey was involved. Therefore, the best way was to establish the conceptual framework of the assessment and improvement on health service quality by literature review and expert advice, and to construct the framework of core concept about health service quality of township 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, this should be a key issue to be resolved.
In addition, this study only addressed the central township health centers in the central and western China's rural poverty areas. The quality characteristics and improvement strategy of health services in common township hospitals and more scopes were not involved. This is still need for continuous improvement and concerns.
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Ⅷ项目/卫生Ⅷ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、Cochran-Armitage趋势检验、Kendall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。
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:①成立领导组织;②开发相关知识手册;③对医务人员保证持续性的培训和宣传教育;④将合理用药制度化;⑤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;⑥与合作医疗和医疗救助等相关制度相结合,形成合力;⑦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:①成立领导组织;②制定和推行《临床诊疗规范》;③进行各类专业培训;④规范医疗文书书写;⑤实施临床诊疗督导;⑥严格乡镇卫生院考评制度;⑦开展技术交流;⑧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:①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。②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。③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。④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)。⑤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Ⅷ项目/卫生Ⅷ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。
Objectives:One of its notable features, the high quality has always been requested in medical and health fields,and the quality problems of health service have also been included in the agenda of all levels of governments. Township health centers, as the knob in the third-class networks, play an important role in the rural health service. In rural poverty areas, health service quality of township health centers, whether or not been sustainablely improved, directly impacts on how to meet farmers’health services needs of degree, and also 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 of township health centers in rural poverty areas, which was supported by B1 area of the eighth projects /support projects in the health. On the basis of these practice measurements and analysis of domestic and foreign relative literatures, this study will attempt to systematically summary the improvement strategies and tactics of health services quality in rural township health centers from the theoretical and practical points, and analyze the results of implementation and the influential factors. These will provide a reference for all levels of governments to improve the health service quality of township health centers in rural poverty areas in the future.
Methods:(1)Literatures and content analysis: The relevant domestic and foreign research data were obtained by searching tools. 120 documents, about the problems of health services quality of township health centers in rural poverty areas, was statistic measured by the use of content analysis. (2)Experts consultation: The questionnaires for the spot survey and interviews outline were defined by experts consultation.The implementation strategies, tactics and influential factors, which were found during survey, were also consulted the advice of experts. (3)Nominal group discussion: Nominal group discussion were applied for the influential factors of rational use of drugs, the influential factors of the implementation effect of standardized clinical treatment, and the effective practice to improve the quality of township health centers in rural poverty areas. (4)Statistical description and statistical inference: The arithmetic average, frequency and rate were used for the relevant descriptive statistics. The hypothesis tests, such as the chi-square test, Cochran-Armitage trend test, Kendall’s coefficient of concordance test were used for statistical inference. The feedback data on the health service quality evaluation were fitted the corresponding model by structural equation model. (5)The method of figure fishbone in operation research: The influential factors of improvement strategies and tactics on the health service quality were systemically sorted out and summed up by the method of figure fishbone in operation research.
Results:The results were achieved by analysis of strategies and tactics of improvement of health service quality of township health centers and its relevant influential factors:(1)There has no uniform definition of health service quality up to the present. The conceptual framework of assessment and improvement of health service quality of township health centers must be clarified in rural poverty areas in future. (2)Besides the structure quality problems such as hardwares, the prominent problems were in the process quality to the present township health centers in rural poverty areas, including the lower trained personnel which caused lower diagnosis and treatment level especially lacking of basic diagnosis and treatment standards and the medical records writing standards, the abuse of drugs especially in antibacterias, hormone and vein infusion, the insufficiency of public health service, and so on. (3)The essential drugs and rational use of drugs strategy and tactics could be devided two parts which were internal and external intervention tactics by its derivation aspect and three parts which were capability, pression and impetus by its effect aspect. These included:①established leader organization;②developed relative knowledge handbooks;③continuous education and propagation of medical personnels;④involve the rational use of drug into regulation;⑤set up effective external assessment and monitor mechanism and adjusted the key point of assessment and monitor according to the situation;⑥cooperation with the cooperative medical schemes and medical finance aid to form composition of forces;⑦fully mobilized the independence and creations of township health centers to boost essential drugs and rational use of drugs strategy. The corresponding influential factors included: the economy of areas, medical stuff, patient, medical organization, macro-circumstance, drug supply, the mechanism of“medical reimbursement by drugs”, medicine information, medical education and non-controlled factors, and so on. (4)The clinical treatment standard strategy and tactics included:①established leader organization;②constituted and implemented the clinical treatment;③educated by various specialty;④standardized medical records writing;⑤monitored the clinical treatment;⑥rigorously implement check system of township health centers;⑦technical communication;⑧multiple monitoring and information feedback. The first five influential factors of clinical treatment strategy included knowledge level of medical stuff, educational level of clinical treatment,treatment habit of medical stuff, whether or not putting the treatment quality and performance assessment together, patient’s health consciousness.(5)The assessment results of the feedback of improvement of township health centers in rural poverty areas showed:①the general best qualtiy aspects included per inpatient cost, improved cure rates, satisfaction of residents;②the general better qualtiy aspects included accessibility of health education, timely vaccination rate of 5 vaccines, Maternal systematical management rate, drug cost per outpatient prescription, reasonable treatment rate, safety of treatment, norm of nurse shift, Omitting rate of the statutory infectious diseases, percentage of essential drugs in outpatient prescription, 2 and more antibacterial drugs 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.③the general common qualtiy aspects included hormone use percent in outpatient, rationality of personnel, relative market share.④the general bad qualtiy aspects included delivery rate in the township health center, 0-7 children medical examination rate, vein infusion percent in outpatient, medical record writing(especial retained record writing).⑤the SEM showed the descending sequential influential factors were rational use of drugs, norm of quality improvement, treatment quality, quality of public health service, intact rate of facilities, medical record writing and rationality of personnel.
Conclusions:The conclusion of this study are:(1)The assessment and improvement of health service quality should meet with medical criterion and satisfaction of residents. But now it must focus on medical criterion.(2)The core point of the assessment and improvement of health service quality is different in different countries even in different development stage in one country.According to township health centers of rural poverty areas, based on continuous improvement of structure quality such as hardwares, essential drugs and rational use of drugs and basic treatment standards should be put to the first now.(3)The final success of all strategies and tactics is based on PDCA cycle. The intervention 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 be paid more attention to improve drug use of township health centers in rural poverty areas now. There are two important tactics. One is mechnism design to correct abuse of drugs by economy factors. The other is continuous education of essential drugs and rational use of drugs, 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 establish national basic diagnosis and treatment standards of township health centers including medical record writing standard. To apply widely, firstly the treatment standards of familiar and excessive diseases should be defined according to different situation. The process can follow from a little to many, from facile to deep method and use appropriate education method accustomed to rural poverty areas. To improve effect of intervention tactics, adult study such as case study and practice should be more accepted.(3)The improvement strategies and tactics should be systematicall designed to form the composition of forces.(4)The grassroot health organization should exert mechanism innovation in health reform 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 study
In this study, based on the practical work of health services quality improvement of township health centers in rural poverty areas over the past 10 years, which was supported by B1 area of the eighth projects / support projects, and combined with the domestic and foreign literatures analysis, the improvement strategies and tactics in health service quality were systematically summed up from both theory and practice points, especially in both essential drugs and rational use of drugs, and regulation of clinical treatment of township health centers in the rural poverty areas. At the same time, the influential factors and effects of implement strategies and tactics were also analyzed. The appropriate strategies and tactics were found. These could provide the reference for government at all levels to improve the health services quality of township health centers in rural poverty areas. This study also constructed the theoretical models for improvement of health services quality of township health centers in rural poverty areas by the methods of structural equation model. The key entry point for quality improvement was found and also was provided for the government and academics as a reference.
2. Drawbacks of this study
The health service quality of township health centers in rural poverty areas contains the very extensive contents. Therefore, the whole contents and all core strategies and tactics cannot be covered during the stage of my doctor degree. While improving the quality of health services is the process of PDCA cycle, the core of intervention point and the corresponding strategies and tactics will also vary with the improvement of health services quality of township health centers in rural poverty areas of China. Limited time, energy and financial constraints, this study was mainly based on“evaluation guide of health services quality of the rural township health centers”. Although these contents were given a relatively detailed and deeply study, some key elements, such as service attitudes of non-technical services, may be left out. Only the satisfaction of the residents on this survey was involved. Therefore, the best way was to establish the conceptual framework of the assessment and improvement on health service quality by literature review and expert advice, and to construct the framework of core concept about health service quality of township 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, this should be a key issue to be resolved.
In addition, this study only addressed the central township health centers in the central and western China's rural poverty areas. The quality characteristics and improvement strategy of health services in common township hospitals and more scopes were not involved. This is still need for continuous improvement and concerns.
引文
1. F.Atherton,G.Mbekem1,I.Nyalusi.Project report.Improving service quality: experience from the Tanzania Family Health Project[J]. International Journal for Quality in Health Care.1999,11:353-356.
2. Primary Care Quality and Information. http://www.wales.nhs.uk/sites3/page.cfm?orgId=719&pid=22921.
3. JOHN OVRETVEIT.A comparison of approaches to health service quality in the UK, USA & Sweden and of the use of organizational audit frameworks. http://eurpub.oxfordjournals.org/cgi/content/abstract/4/1/46.
4. Christine C. Wright,D.Whittington,H.McKenna,etc. Quality assurance:an introduction for health care professionals.Edinburgh,New York:Churchill Livingstone.1992.
5. Victor Sower,JoAnn Duffy,William Kilbourne,etc. The Dimensions on Service Quality for Hospitals:Development and Use of the KQCAH Scale [J]. Health Care Management Review,2001,26.
6. National Health Service Quality Improvement Scotland (NHS QIS). http://www.euro.who.int/HEN/Resources/NHS/20050418_1.
7. Christine C.Wright,etc. 1992, Quality Assurance: An Introduction for Health Care Professionals. Churchill Livingstone, Edinburgh.
8. World Health Organization.How to investigate drug use in health facilities selected druguse indicators[M].WHO,1993.
9. Health Service Quality - An Introduction to Quality Methods for Health Services. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1055075.
10.伍丽红,李欣红,袁庆才,等.医疗质量评价.国外医学.医院管理分册,2001;第1期:20-21
11. M.I.Roemer and C.Montoya-Aguilar.1998, Quality Assessment and Assurance in Primary Health Care. WHO Offset Publication, World Health Organization, Geneva, Switzerland.
12. Abraham Israeli, Samuel Penchas.1997,“Quantity in Health Care is not always a Substitute for Quality”. International Journal of Health Care Quality Assurance ,Vol.10 No.1 PP27-30.
13. A Framework for Managing the Quality of Health Services in New South Wales. http://www.health.nsw.gov.au/quality/pdf/framework.pdf
14. F. Sim, and P. Mackiea. When is public health really going to influence service quality?.
15.张鹭鹭.医疗质量评价的发展.解放军医院管理杂志,1997;4(4):391-393.
16.韩世新.医院医疗质量评价方法现状及进展.第四军医大学学报,2001;22:61-62.
17. John.A.Bavoro.医疗服务质量改进与风险管理.中华医院管理,2000;16(6):383.
18. Richard Davis. 1995,“A Real Job for Managers in the Health Service”. International Journal of Health Care Quality Assurance,Vol.8 No.5 PP13-16.
19. Joesph P. Newhouse. 2002,“Why is There a Quality Chasm? The Barriers to Good Performance are More Fundamental than Simply the Lack of Organized Systems”. Health Affairs, July-August.
20.李宪英.医疗服务质量监控体系的建立.www.allbrightlaw.com.cn.
21.唐本雄.美国的卫生保健体制(II).中国初级卫生保健,2002;16(4):61-63.
22.郭琦,张鹭鹭,范思昌,等.顾客原理在持续性医疗质量提高中的应用.中华医院管理杂志,2000;16(9):556-558.
23. Christian Gronroos(2000),Service Management and Marketing,Lexington Books,1990.
24. A first class service: Quality in the new NHS. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006902.
25. Guidelines for Ensuring the Quality of Information Disseminated to the Public of Indian Health Service. http://aspe.hhs.gov/infoQuality/Guidelines/ihsinfo2.shtml.
26.邹爱东,张群.提高患者满意度的一种新途径.国外医学.医院管理分册,2000;No.1:9-11.
27. Stephen J. O’Connor,Hanh Q.Trinh,RichardM Shewchuk. Perceptual Gaps in Understanding Patient Expectations for Health Care Service Quality[J]. Health CareManage Review,2000,25(2):7-23.
28. Wendy Leebov, Gail Scott. 1994, The Customer Satisfactory Strategy for Health Care. USA: American hospital publishing.
29. SOERJO HADIJONO.Health Service Quality Improvement after Normal Delivery Competency-based Training Package. 8TH POST GRADUATE COURSE FOR TRAINING IN REPRODUCTIVE MEDICINE & REPRODUCTIVE BIOLOGY GENEVA, 1998.
30. Parasuraman,Zeithaml,V. and L. Berry(1988):SERVQUAL,A Multiple-Item Scale for Measuring Consumer Perceptions of Service Quality. Journal of Retailing,Vol.64,1(spring),pp.12-401.
31. Reviewing Healthcare. Improving Quality. http://www.permedion.com/AboutPermedion.htm.
32. The National Health Service (Improved Access, Quality Information Preparation and Violent Patients Schemes) (England) Regulations 2003. Statutory Instrument 2003 No. 2824.
33. Health Service Circular. http://www.nepho.org.uk/view_file.php?c=2091.
34. Quality and Service. http://www.ohsu.edu/health/page.cfm?id=10001.
35. Quality Improvement of District Health Services.JFY 2006. http://www.med.tohoku.ac.jp/kyomu/in/international/Seminar_eng.pdf.
36. Ross S Bailie, Damin Si, Lyn O’Donoghue, Michelle Dowden.Indigenous health: effective and sustainable health services through continuous qualityimprovement[J]. MJA 2007,186 (10): 525-527.
37.薛迪,陈洁.社区医疗服务质量评价的意义与方法.中华医院管理杂志,1999;15(4):216-218.
38.嵇芸,吴布生,陆龙.军队医院与医疗质量评价的若干问题.解放军医院管理杂志,1999;6(1):23-25.
39.郭子恒.医院管理学(第3版).北京:人民卫生出版社,1990.
40. Dagger et al. A Hierarchical Model of Health Service Quality: Scale Development and Investigation. Journal of Service Research.2007,10: 123-142.
41.唐本雄.美国的卫生保健体制(I).中国初级卫生保健,2002;16(3):60-63.
42.许树才,吕玉波.医疗质量的评价与改善.国外医院.医院管理分册,1998;1:10
43. Health service quality on the rise ?the results are in. http://www.hqcc.qld.gov.au/home/news_detail.asp?newsid=34.
44.李小民,韩建军等.浅析医院在医疗服务质量绩效管理中存在的问题.海南医学,2002;13(9):75-76.
45.方积乾,周凤琼,张寿生.试论医院服务质量的评价与保障.中华医院管理杂志,2002;18(10):630-632.
46.向悟海编译.用患者满意度评价医疗质量.国外医学.卫生经济分册,1995;12(2):85-88.
47.黄伟灿,李静,张罗漫,等.军队医院综合质量评价指标体系的研究与应用.第二军医大学学报,2002;23(7):719-723.
48.董燕敏,刘联华,刘宝松,等.社区卫生服务质量管理的探索.中国全科医学杂志,2000;3(4):282-284.
49. Adrienne Curry,etc.1999,“Patient and Stakeholder Consultation in Healthcare”.Managing Service Qualtiy,Vol.9 No.5 PP327-336.
50. Penelope Angelopoulou,etc..1998,“Private and Public Medicine: A Comparison of Qualtiy Perceptions”. International Journal of Health CareQuality Assurance ,Vol.11 No.1 PP14-20.
51. J.McCrindle, R.K.Jones.1998,“Preliminary Evaluation of the Efficacy and Implementation of the New NHS Complaints Procedure”. International Journal of Health Care Quality Assurance ,Vol.11 No.2 PP41-44.
52. Ton Van der Wiele, etc..2002,“Empirical Evidence for the Relationship between Customer Satisfaction and Business Performance”. Managing Service Quality,Vol.12 No.3 PP184-193.
53. Reva Berman Brown, Louise Bell. 1998,“Patient-centred Audit: A Users’Quality Model”. Managing Service Quality,Vol.8 No.2 PP88-96.
54. Angela Coulter, Paul D.Cleary. 2001,“Patients’Experiences with Hospital Care in Five Countries: Patients’Assessments of Hospital Care are Essential to Improving its Quality”. Health Affairs, May-June.
55. Ingemar Eckerlund,etc.1997,“Change-oriented Patient Questionnaires-testing a New Method at Three Departments of Ophthalmology”. International Journal of Health Care Quality Assurance,Vol.10 No.7 PP254-259.
56.王兴勇,卢仲毅,肖农.医疗质量管理与服务技巧. www.xdyy.net.
57. Quality Health New Zealand. http://www.qualityhealth.org.nz.
58. Health Quality Council of Alberta Regulation, Alta. Reg. http://www.canlii.org/ab/laws/regu/2006r.130/20080415/whole.html.
59. Tracey S. Dagger.A Hierarchical Model of Health Service Quality. http://jsr.sagepub.com/cgi/content/abstract/10/2/123.
60. Access to Quality Health Services. http://www.healthypeople.gov/Document/HTML/Volume1/01Access.htm.
1. Christian Gronroos(2000),Service Management and Marketing,Lexington Books,1990.
2. Parasuraman,Zeithaml,V. and L. Berry(1988):SERVQUAL,A Multiple-Item Scale for Measuring Consumer Perceptions of Service Quality. Journal of Retailing,Vol.64,1(spring),pp.12-401.
3.张卫兵:医疗质量管理的决策和实践[J].解放军医院管理杂志,2001, 1: 25-26.
4. Coddington. D.,Moore. K. Quality of Care as a Business Strategy:How Customers Define Quality and How to Market It[J]. Healthcare Forum,1987, 30 (2):29 - 32.
5. Duffy. Jo Ann,Duffy. Michael,Kilbourne. William. Cross National Study of Perceived Service Quality in Long - Term Care Facilities[J]. Journal of Aging Studies,1997,11(4):327.
6. Stephen J. O’Connor,Hanh Q.Trinh,RichardM Shewchuk. Perceptual Gaps in Understanding Patient Expectations for Health CareService Quality[J]. Health CareManage Review,2000,25(2):7-23.
7.王冬,张罗漫.医疗质量评价指标的回顾与分析[J] .中华医院管理杂志,2001, (2):90-92.
8.韩世新.医院医疗质量评价方法现状及进展[J].第四军医大学学报,2001,(2): 61-62.
9.张朝阳.我国乡镇卫生院发展现状及其影响因索分析[J].中国医院管理,2005,6(6):263.
10.博卫,孙奕,孙军安,卢祖洵.农村乡镇卫生院合理用药及其管理措施分析[J].中国卫生经济,2004,6(6):23.
11.唐爱平,颜虹,陈莹.贫困地区乡镇卫生院药物使用现状浅析[J].中国农村卫生事业管理,2002,22(10):59.
12.牛宏俐,张亮,张翔,王静,苏克俭,吴焕才.卫生Ⅷ干预地区促进合理用药策略探讨[J].医学与社会,2005,l8(9):3.
13.冯旭,任苒.我国西部农村乡镇卫生院药品收支与处方用药分析[J].中国初级卫生保健,2003,l7 (l0):14.
14. World Health Organization.How to investigate drug use in health facilities selected druguse indicators[M].WHO,1993.
15.张翔,冯占春,张亮,张洁欣.卫Ⅷ干预地区乡镇卫生院处方书写质量研究[J].中国初级卫生保健,2003,l7(10):16-18.
16.张翔,冯占春,张亮,张洁欣.贫困地区乡镇卫生院处方质量分析[J].中国农村卫生事业管理,2003,12(23).
17.张翔,张亮,冯占春,陈叙,王帮金,武晨呜,江震.部分乡镇卫生院住院病历书写现状分析[J].中华医院管理杂志,2005,21(3):194.
18.冯文,苏维,王禄生,郭子瑜,张楷莹.管理培训对乡镇卫生院作用的分析[J].中国农村卫生事业管理,2006,26(4):17-19.
19.力晓蓉,易易,陈运,黄晓林,杨庆,刘秦民,张菊英,秦正积,陈俊.四川省乡镇卫生院卫生技术人员在职培训现状调查[J].中国卫生事业管理,2007,(1):43-45.
20.陈凤侠.乡镇卫生院健康教育方法探讨[J].哈尔滨医药,2003,23(5):25.
21.杨敏,王大连. 20所乡镇卫生院消毒管理现状分析与对策[J].护理与康复,2005, 4(3):173.
22.施焕鱼. 32所乡镇卫生院医院感染管理现状调查及对策[J].护理研究,2005,19 (7):1393.
23.俞琬如,许淑琴,单东良,张彩凤,孙迎芳,张莲娣,沈小娟.乡镇卫生院医院感染管理现状及对策[J].中华医院感染学杂志,2005,15(4):433.
24.庹惠芬.乡镇卫生院护理工作现状与对策[J].医学临床研究,2006,23(1):140.
25.梁俊华,杜长青,石忠曙.浅谈乡镇卫生院护理管理的现状与对策[J].中国乡村医药杂志,2002,9(12):72.
26.李伟.乡镇放射防护工作存在的问题及对策[J].中国社会医学,2005,11(1).
27.苏首勋,周凯,何立兵.濮阳市乡镇卫生院医用诊断X射线工作防护现状及对策[J].中国职业医学,2005,32(5):68.
28.施培武,罗力,李强,岳建宁,罗实,郝模.基层卫生机构应承担的疾病预防控制职能和工作项目界定[J].卫生研究,34(6):704.
29.肖锦铖,周成红乡镇卫生院制定卫生服务标准的困难及基本对策[J].中国初级卫生保健,2002,16(1):29.
30.王静,张亮,冯占春.农村乡镇卫生院服务质量评价指标分析[J].中国卫生事业,2006,2:212.
31.王静,张亮,冯占春,牛宏俐,张翔.农村乡镇卫生院服务质量评价主体研究[J].中国医院管理,2006,26(5):28.
32. Christine C. Wright,D.Whittington,H.McKenna,etc. Quality assurance:an introduction for health care professionals.Edinburgh,New York:Churchill Livingstone.1992.
33. Adam Wagstaff and Shengchao Yub. Do Health Sector Reforms Have Their Intended Impacts?The World Bank's Health VIII Project in Gansu Province, China. Development Research Group and East Asia Region,The World Bank, Washington DC,USA World Bank Office Beijing,China.2005 November.
34.李长明.中国农村卫生事业发展现状与策略思考.中国农村卫生事业管理[J],2000,20(11):3-6.
35.吴建.加强乡镇卫生院医疗质量控制的实践与体会[J].中国卫生事业管理,2006,4.
36.提高乡镇卫生院卫生服务质量的基本策略[J].中国卫生政策,2001(4).
37.罗忠科.提高卫生院管理水平改善卫生院服务质量-陕西省项口区卫生服务管理水平分析[J].中国初级卫生保健,2005,19 (5):82.
38.中华人民共和国卫生部国外贷款办公室.中国基本卫生服务项目(卫生Ⅷ项目)研究前言[J].中国初级卫生保健,2005,19(5):1
39.王万荣.提高卫生管理水平改善农村卫生服务质量-安徽省卫生Ⅷ干预地区卫生服务管理水平分析[J].中国初级卫生保健,2002,16(12):24.
40.卫生部国外贷款办公室(卫贷办便函[2006]50号).关于开展卫生服务质量评价与改进活动的通知.2006.
41.冯占春,熊占路,张亮,张翔,贾欣增.贫困地区5所乡镇卫生院卫生服务质量现状及其改进研究[J].中国医院管理,2006,26(10):13.
42. Victor Sower,JoAnn Duffy,William Kilbourne,etc. The Dimensions on Service Quality for Hospitals:Development and Use of the KQCAH Scale [J]. Health Care Management Review,2001,26.
2. Primary Care Quality and Information. http://www.wales.nhs.uk/sites3/page.cfm?orgId=719&pid=22921.
3. JOHN OVRETVEIT.A comparison of approaches to health service quality in the UK, USA & Sweden and of the use of organizational audit frameworks. http://eurpub.oxfordjournals.org/cgi/content/abstract/4/1/46.
4. Christine C. Wright,D.Whittington,H.McKenna,etc. Quality assurance:an introduction for health care professionals.Edinburgh,New York:Churchill Livingstone.1992.
5. Victor Sower,JoAnn Duffy,William Kilbourne,etc. The Dimensions on Service Quality for Hospitals:Development and Use of the KQCAH Scale [J]. Health Care Management Review,2001,26.
6. National Health Service Quality Improvement Scotland (NHS QIS). http://www.euro.who.int/HEN/Resources/NHS/20050418_1.
7. Christine C.Wright,etc. 1992, Quality Assurance: An Introduction for Health Care Professionals. Churchill Livingstone, Edinburgh.
8. World Health Organization.How to investigate drug use in health facilities selected druguse indicators[M].WHO,1993.
9. Health Service Quality - An Introduction to Quality Methods for Health Services. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1055075.
10.伍丽红,李欣红,袁庆才,等.医疗质量评价.国外医学.医院管理分册,2001;第1期:20-21
11. M.I.Roemer and C.Montoya-Aguilar.1998, Quality Assessment and Assurance in Primary Health Care. WHO Offset Publication, World Health Organization, Geneva, Switzerland.
12. Abraham Israeli, Samuel Penchas.1997,“Quantity in Health Care is not always a Substitute for Quality”. International Journal of Health Care Quality Assurance ,Vol.10 No.1 PP27-30.
13. A Framework for Managing the Quality of Health Services in New South Wales. http://www.health.nsw.gov.au/quality/pdf/framework.pdf
14. F. Sim, and P. Mackiea. When is public health really going to influence service quality?.
15.张鹭鹭.医疗质量评价的发展.解放军医院管理杂志,1997;4(4):391-393.
16.韩世新.医院医疗质量评价方法现状及进展.第四军医大学学报,2001;22:61-62.
17. John.A.Bavoro.医疗服务质量改进与风险管理.中华医院管理,2000;16(6):383.
18. Richard Davis. 1995,“A Real Job for Managers in the Health Service”. International Journal of Health Care Quality Assurance,Vol.8 No.5 PP13-16.
19. Joesph P. Newhouse. 2002,“Why is There a Quality Chasm? The Barriers to Good Performance are More Fundamental than Simply the Lack of Organized Systems”. Health Affairs, July-August.
20.李宪英.医疗服务质量监控体系的建立.www.allbrightlaw.com.cn.
21.唐本雄.美国的卫生保健体制(II).中国初级卫生保健,2002;16(4):61-63.
22.郭琦,张鹭鹭,范思昌,等.顾客原理在持续性医疗质量提高中的应用.中华医院管理杂志,2000;16(9):556-558.
23. Christian Gronroos(2000),Service Management and Marketing,Lexington Books,1990.
24. A first class service: Quality in the new NHS. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006902.
25. Guidelines for Ensuring the Quality of Information Disseminated to the Public of Indian Health Service. http://aspe.hhs.gov/infoQuality/Guidelines/ihsinfo2.shtml.
26.邹爱东,张群.提高患者满意度的一种新途径.国外医学.医院管理分册,2000;No.1:9-11.
27. Stephen J. O’Connor,Hanh Q.Trinh,RichardM Shewchuk. Perceptual Gaps in Understanding Patient Expectations for Health Care Service Quality[J]. Health CareManage Review,2000,25(2):7-23.
28. Wendy Leebov, Gail Scott. 1994, The Customer Satisfactory Strategy for Health Care. USA: American hospital publishing.
29. SOERJO HADIJONO.Health Service Quality Improvement after Normal Delivery Competency-based Training Package. 8TH POST GRADUATE COURSE FOR TRAINING IN REPRODUCTIVE MEDICINE & REPRODUCTIVE BIOLOGY GENEVA, 1998.
30. Parasuraman,Zeithaml,V. and L. Berry(1988):SERVQUAL,A Multiple-Item Scale for Measuring Consumer Perceptions of Service Quality. Journal of Retailing,Vol.64,1(spring),pp.12-401.
31. Reviewing Healthcare. Improving Quality. http://www.permedion.com/AboutPermedion.htm.
32. The National Health Service (Improved Access, Quality Information Preparation and Violent Patients Schemes) (England) Regulations 2003. Statutory Instrument 2003 No. 2824.
33. Health Service Circular. http://www.nepho.org.uk/view_file.php?c=2091.
34. Quality and Service. http://www.ohsu.edu/health/page.cfm?id=10001.
35. Quality Improvement of District Health Services.JFY 2006. http://www.med.tohoku.ac.jp/kyomu/in/international/Seminar_eng.pdf.
36. Ross S Bailie, Damin Si, Lyn O’Donoghue, Michelle Dowden.Indigenous health: effective and sustainable health services through continuous qualityimprovement[J]. MJA 2007,186 (10): 525-527.
37.薛迪,陈洁.社区医疗服务质量评价的意义与方法.中华医院管理杂志,1999;15(4):216-218.
38.嵇芸,吴布生,陆龙.军队医院与医疗质量评价的若干问题.解放军医院管理杂志,1999;6(1):23-25.
39.郭子恒.医院管理学(第3版).北京:人民卫生出版社,1990.
40. Dagger et al. A Hierarchical Model of Health Service Quality: Scale Development and Investigation. Journal of Service Research.2007,10: 123-142.
41.唐本雄.美国的卫生保健体制(I).中国初级卫生保健,2002;16(3):60-63.
42.许树才,吕玉波.医疗质量的评价与改善.国外医院.医院管理分册,1998;1:10
43. Health service quality on the rise ?the results are in. http://www.hqcc.qld.gov.au/home/news_detail.asp?newsid=34.
44.李小民,韩建军等.浅析医院在医疗服务质量绩效管理中存在的问题.海南医学,2002;13(9):75-76.
45.方积乾,周凤琼,张寿生.试论医院服务质量的评价与保障.中华医院管理杂志,2002;18(10):630-632.
46.向悟海编译.用患者满意度评价医疗质量.国外医学.卫生经济分册,1995;12(2):85-88.
47.黄伟灿,李静,张罗漫,等.军队医院综合质量评价指标体系的研究与应用.第二军医大学学报,2002;23(7):719-723.
48.董燕敏,刘联华,刘宝松,等.社区卫生服务质量管理的探索.中国全科医学杂志,2000;3(4):282-284.
49. Adrienne Curry,etc.1999,“Patient and Stakeholder Consultation in Healthcare”.Managing Service Qualtiy,Vol.9 No.5 PP327-336.
50. Penelope Angelopoulou,etc..1998,“Private and Public Medicine: A Comparison of Qualtiy Perceptions”. International Journal of Health CareQuality Assurance ,Vol.11 No.1 PP14-20.
51. J.McCrindle, R.K.Jones.1998,“Preliminary Evaluation of the Efficacy and Implementation of the New NHS Complaints Procedure”. International Journal of Health Care Quality Assurance ,Vol.11 No.2 PP41-44.
52. Ton Van der Wiele, etc..2002,“Empirical Evidence for the Relationship between Customer Satisfaction and Business Performance”. Managing Service Quality,Vol.12 No.3 PP184-193.
53. Reva Berman Brown, Louise Bell. 1998,“Patient-centred Audit: A Users’Quality Model”. Managing Service Quality,Vol.8 No.2 PP88-96.
54. Angela Coulter, Paul D.Cleary. 2001,“Patients’Experiences with Hospital Care in Five Countries: Patients’Assessments of Hospital Care are Essential to Improving its Quality”. Health Affairs, May-June.
55. Ingemar Eckerlund,etc.1997,“Change-oriented Patient Questionnaires-testing a New Method at Three Departments of Ophthalmology”. International Journal of Health Care Quality Assurance,Vol.10 No.7 PP254-259.
56.王兴勇,卢仲毅,肖农.医疗质量管理与服务技巧. www.xdyy.net.
57. Quality Health New Zealand. http://www.qualityhealth.org.nz.
58. Health Quality Council of Alberta Regulation, Alta. Reg. http://www.canlii.org/ab/laws/regu/2006r.130/20080415/whole.html.
59. Tracey S. Dagger.A Hierarchical Model of Health Service Quality. http://jsr.sagepub.com/cgi/content/abstract/10/2/123.
60. Access to Quality Health Services. http://www.healthypeople.gov/Document/HTML/Volume1/01Access.htm.
1. Christian Gronroos(2000),Service Management and Marketing,Lexington Books,1990.
2. Parasuraman,Zeithaml,V. and L. Berry(1988):SERVQUAL,A Multiple-Item Scale for Measuring Consumer Perceptions of Service Quality. Journal of Retailing,Vol.64,1(spring),pp.12-401.
3.张卫兵:医疗质量管理的决策和实践[J].解放军医院管理杂志,2001, 1: 25-26.
4. Coddington. D.,Moore. K. Quality of Care as a Business Strategy:How Customers Define Quality and How to Market It[J]. Healthcare Forum,1987, 30 (2):29 - 32.
5. Duffy. Jo Ann,Duffy. Michael,Kilbourne. William. Cross National Study of Perceived Service Quality in Long - Term Care Facilities[J]. Journal of Aging Studies,1997,11(4):327.
6. Stephen J. O’Connor,Hanh Q.Trinh,RichardM Shewchuk. Perceptual Gaps in Understanding Patient Expectations for Health CareService Quality[J]. Health CareManage Review,2000,25(2):7-23.
7.王冬,张罗漫.医疗质量评价指标的回顾与分析[J] .中华医院管理杂志,2001, (2):90-92.
8.韩世新.医院医疗质量评价方法现状及进展[J].第四军医大学学报,2001,(2): 61-62.
9.张朝阳.我国乡镇卫生院发展现状及其影响因索分析[J].中国医院管理,2005,6(6):263.
10.博卫,孙奕,孙军安,卢祖洵.农村乡镇卫生院合理用药及其管理措施分析[J].中国卫生经济,2004,6(6):23.
11.唐爱平,颜虹,陈莹.贫困地区乡镇卫生院药物使用现状浅析[J].中国农村卫生事业管理,2002,22(10):59.
12.牛宏俐,张亮,张翔,王静,苏克俭,吴焕才.卫生Ⅷ干预地区促进合理用药策略探讨[J].医学与社会,2005,l8(9):3.
13.冯旭,任苒.我国西部农村乡镇卫生院药品收支与处方用药分析[J].中国初级卫生保健,2003,l7 (l0):14.
14. World Health Organization.How to investigate drug use in health facilities selected druguse indicators[M].WHO,1993.
15.张翔,冯占春,张亮,张洁欣.卫Ⅷ干预地区乡镇卫生院处方书写质量研究[J].中国初级卫生保健,2003,l7(10):16-18.
16.张翔,冯占春,张亮,张洁欣.贫困地区乡镇卫生院处方质量分析[J].中国农村卫生事业管理,2003,12(23).
17.张翔,张亮,冯占春,陈叙,王帮金,武晨呜,江震.部分乡镇卫生院住院病历书写现状分析[J].中华医院管理杂志,2005,21(3):194.
18.冯文,苏维,王禄生,郭子瑜,张楷莹.管理培训对乡镇卫生院作用的分析[J].中国农村卫生事业管理,2006,26(4):17-19.
19.力晓蓉,易易,陈运,黄晓林,杨庆,刘秦民,张菊英,秦正积,陈俊.四川省乡镇卫生院卫生技术人员在职培训现状调查[J].中国卫生事业管理,2007,(1):43-45.
20.陈凤侠.乡镇卫生院健康教育方法探讨[J].哈尔滨医药,2003,23(5):25.
21.杨敏,王大连. 20所乡镇卫生院消毒管理现状分析与对策[J].护理与康复,2005, 4(3):173.
22.施焕鱼. 32所乡镇卫生院医院感染管理现状调查及对策[J].护理研究,2005,19 (7):1393.
23.俞琬如,许淑琴,单东良,张彩凤,孙迎芳,张莲娣,沈小娟.乡镇卫生院医院感染管理现状及对策[J].中华医院感染学杂志,2005,15(4):433.
24.庹惠芬.乡镇卫生院护理工作现状与对策[J].医学临床研究,2006,23(1):140.
25.梁俊华,杜长青,石忠曙.浅谈乡镇卫生院护理管理的现状与对策[J].中国乡村医药杂志,2002,9(12):72.
26.李伟.乡镇放射防护工作存在的问题及对策[J].中国社会医学,2005,11(1).
27.苏首勋,周凯,何立兵.濮阳市乡镇卫生院医用诊断X射线工作防护现状及对策[J].中国职业医学,2005,32(5):68.
28.施培武,罗力,李强,岳建宁,罗实,郝模.基层卫生机构应承担的疾病预防控制职能和工作项目界定[J].卫生研究,34(6):704.
29.肖锦铖,周成红乡镇卫生院制定卫生服务标准的困难及基本对策[J].中国初级卫生保健,2002,16(1):29.
30.王静,张亮,冯占春.农村乡镇卫生院服务质量评价指标分析[J].中国卫生事业,2006,2:212.
31.王静,张亮,冯占春,牛宏俐,张翔.农村乡镇卫生院服务质量评价主体研究[J].中国医院管理,2006,26(5):28.
32. Christine C. Wright,D.Whittington,H.McKenna,etc. Quality assurance:an introduction for health care professionals.Edinburgh,New York:Churchill Livingstone.1992.
33. Adam Wagstaff and Shengchao Yub. Do Health Sector Reforms Have Their Intended Impacts?The World Bank's Health VIII Project in Gansu Province, China. Development Research Group and East Asia Region,The World Bank, Washington DC,USA World Bank Office Beijing,China.2005 November.
34.李长明.中国农村卫生事业发展现状与策略思考.中国农村卫生事业管理[J],2000,20(11):3-6.
35.吴建.加强乡镇卫生院医疗质量控制的实践与体会[J].中国卫生事业管理,2006,4.
36.提高乡镇卫生院卫生服务质量的基本策略[J].中国卫生政策,2001(4).
37.罗忠科.提高卫生院管理水平改善卫生院服务质量-陕西省项口区卫生服务管理水平分析[J].中国初级卫生保健,2005,19 (5):82.
38.中华人民共和国卫生部国外贷款办公室.中国基本卫生服务项目(卫生Ⅷ项目)研究前言[J].中国初级卫生保健,2005,19(5):1
39.王万荣.提高卫生管理水平改善农村卫生服务质量-安徽省卫生Ⅷ干预地区卫生服务管理水平分析[J].中国初级卫生保健,2002,16(12):24.
40.卫生部国外贷款办公室(卫贷办便函[2006]50号).关于开展卫生服务质量评价与改进活动的通知.2006.
41.冯占春,熊占路,张亮,张翔,贾欣增.贫困地区5所乡镇卫生院卫生服务质量现状及其改进研究[J].中国医院管理,2006,26(10):13.
42. Victor Sower,JoAnn Duffy,William Kilbourne,etc. The Dimensions on Service Quality for Hospitals:Development and Use of the KQCAH Scale [J]. Health Care Management Review,2001,26.