醫院結核病個案管理模式之探討

醫院結核病個案管理模式之探討

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醫院採取的策略型態會影響到其運作，包括績效衡量和評估系統的設計等。傳統上多以財務面的結 果來代表經營績效，常因此忽略能讓醫院永續經營的動力。因此， Kaplan & Norton 於 1990 年提出

「平衡計分卡」的概念，除了「財務面」外，也重視「顧客面」、「企業內部流程面」和「學習與 成長面」等非財務指標，並將組織的使命和策略整合為一套全方位的績效評量架構。

本研究結合 Miles & Snow 於 1978 年提出的四種策略型態與平衡計分卡之概念，以結構性問卷作為 測量工具，對於台灣地區 126 家地區教學級以上醫院所採取的策略型態及其對績效評估指標看法予 以分析探討。回收之有效問卷共 70 份（回收率為 55.6% ），而使用之統計分析方法包括卡方檢定

、皮爾森積差相關、單因子變異數分析及 Tukey’s 事後檢定等。

研究結果顯示，地區教學級以上醫院採用分析者策略者佔最多數（ 51.4% ），其次是採取前瞻者策 略的醫院（佔 18.6% ），再其次為採取防禦者策略的醫院（佔 15.7% ），最少數的則為採取反應者 策略的醫院（佔 14.3% ）。醫院採取的策略型態會影響其對顧客、內部流程及學習與成長構面等指 標資料取得方便性上的看法，而採取防禦者策略的醫院相較於採取其他三項策略型態的醫院而言，

認為在上述三類構面之指標資料取得上較不方便。

因此，本研究提出下述建議：一、建議衛生主管機關能在參考平衡計分卡的概念，以建立一套更全 面性的醫院評鑑標準；二、建議醫院管理者在設計績效評估指標時，必須與本身策略進行聯結，才 能更有效地管控醫院營運狀況，且應更注重顧客及學習與成長構面指標的衡量。三、建議後續研究 者，可採縱貫面方式以進一步瞭解環境的變遷對醫院策略取向上的影響程度。

Analysis of Tuberculosis Case Management Models in Hospitals

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The Bureau of National Health Insurance (BNHI) implemented the pay-for-quality demonstration program in November 2001, targeting tuberculosis, breast cancer, cer vical cancer, asthma, and diabetes. The aim of the program is to encourage health care organizations to adopt the strategy of disease management by assembling health care teams as to to improve the medical care outcomes of patients with the aforementioned chronic diseases. And the key successful factor of disease management is to establish a case management model.

The purposes of this study were to investigate the current state of tuberculosis patient management in Taiwan’s hospitals, and identify components of tuberculosis case management models. Furthermore, the impact of hospital characteristics on the inclusion of various tuberculosis case management model components was analyzed.

Using the 2001-2004 hospital accreditation data, the study population comprised 492 district hospitals or above in Taiwan, after excluding those hospitals that were no longer in operation. People who were in charge of tuberculosis patient management in those hospitals were explicitly asked to respond to the survey. In early March 20 06, self-administered questionnaires were mailed out to those identified hospitals. Two rounds of follow-up mailings were carried out. In the end, there were 388 questi onnaires returned by late May, representing a 78.9% response rate. Among those questionnaires, there were 244 hospitals (62.9%) engaging in treating tuberculosis pat ients; however, four of them declined to participated in this survey further. As such, the final effective sample size was 240. Chi-squared test and logistic regression an alysis were conducted to examine the impact of hospital characteristics on the adoption of tuberculosis case management models.

The results showed that sample hospitals’ tuberculosis case management model components could be classified as: manpower allocation, admission management, data buildup, treatment management, nursing instruction, revisit management, and referral management. Inferential statistics results were as follows. (1). Manpower allocati on – Hospital level was significantly related to if sample hospitals would employ full-time tuberculosis case managers (χ2 = 69.1, p < 0.001). Medical centers were mor e likely to designate full-time tuberculosis case managers. On the other hand, district hospitals tended to appoint part-time tuberculosis case managers instead. Moreove r, the likelihood of those hospitals that enrolled in the tuberculosis pay-for-quality demonstration program appointing full-time tuberculosis case managers was as high as four times that of non-enrolled hospitals (OR = 4.29, p < 0.001). (2). Admission management - Hospital level was also significantly related to if sample hospitals wo uld prescribe rules regarding admitting tuberculosis patients (χ2 = 19.9, p < 0.001). Medical centers were less likely to lay down such kind of rules, compared to their c ounterparts. (3). Data buildup - Hospital level was significantly related to methods of data buildup of sample hospitals as well (χ2 = 23.8, p < 0.001). District hospitals tended to use the tuberculosis patient database management system provided by the Center for Disease Control (CDC) of Taiwan, rather than design their own systems, compared to their counterparts. In addition, compared to non-enrolled hospitals, hospitals that enrolled in the tuberculosis pay-for-quality demonstration program were more likely to design their own tuberculosis patient database management systems, along with using the existing system of the CDC (OR = 2.49, p < 0.01). (4). Treatm ent management - The results showed that the possibility of if sample hospitals would create an ad hoc committee to be responsible for treating tuberculosis patients dif fered significantly by hospital level (χ2 = 52.3, p < 0.001). District hospitals were less likely to establish such a committee, among all. Furthermore, hospitals that enrol led in the tuberculosis pay-for-quality demonstration program were more likely to create such a committee, compared to their counterparts (OR = 3.82, p < 0.001). (5).

Nursing instruction – The results revealed that hospital level was not significantly related to if sample hospitals would designate tuberculosis case managers in charge o f related nursing instruction. However, hospitals that enrolled in the tuberculosis pay-for-quality demonstration program were more likely to set up specific nursing inst ruction places for tuberculosis patients than non-enrolled hospitals (OR ＝ 4.04, p < 0.001). (6). Revisit management - Hospital level was significantly related to if sam ple hospitals would actively arrange revisits for their tuberculosis patients (χ2 = 14.2, p < 0.001). District hospitals were more likely to have revisit management, comp ared to their counterparts. (7). Referral management – Finally, hospital level was significantly related to if sample hospitals would carry out referral management for th eir tuberculosis patients as well (χ2 = 14.4, p = 0.001). Among all levels of hospitals, district hospitals were most likely to notify those responsible community public n urses when their tuberculosis patients were discharged.

In conclusion, this study demonstrated that hospital characteristics did exert impact on the inclusion of various tuberculosis case management model components by ho spitals. According to research findings, the following policy recommendations were proposed: (1). The government should systematically develop tuberculosis manage ment manpower. (2). Hospital accreditation items should include manpower allocation with respect to tuberculosis case management. (3). The government should estab lish a comprehensive medical care network for treating tuberculosis patients. (4). The government should promote tuberculosis case management models aggressively.

(5). Various tuberculosis patient database management systems need to be integrated to increase the accessibility for users. (6). The role played by community public h

ealth nurses should be enhanced regarding treating tuberculosis patients.