1、华中科技大学硕士学位论文临床路径管理的关键环节与控制策略研究硕士研究生：郭淑岩指 导 教 师：陶红兵中文摘要临床路径作为一种新的质量管理模式，以其在提高医疗质量，保障医疗安全，降低医疗费用方面的巨大作用，受到我国卫生行政部门和医院管理者的普遍关注。总结国外实施临床路径的实践经验不难发现，实施临床路径管理是一个系统的全方位工程，不仅对医院的整体实力要求较高，而且还需要医院具有高较的医院管理水平、管理层具有先进的经营理念，医院具有合理的人力资源配置，配套相关激励约束机制等。但是，我国在实施临床路径过程中，还存在医院管理者管理理念落后，医院基础设施建设和信息系统建设相对滞后，医疗保险机制不健全，医疗
2、费用补偿机制不配套等一系列问题，很多医院缺乏开展临床路径管理的内部动力和外部压力。导致临床路径在我国的发展达不到预期效果，临床路径管理模式未得到广泛应用。本研究拟通过探索临床路径管理过程中的关键环节，对医院临床路径管理中存在的问题进行系统分析并制定有效的控制策略，通过样本医院实施效果分析临床路径管理关键环节控制的可行性，促进临床路径管理全面发展与重点环节控制相结合，进而建立临床路径管理长效发展机制，为我国医院开展临床路径管理提供理论和实践依据。资料来源与方法本文采用定性研究与定量数据分析相结合的方法，对 32 名医院管理者及相关人员进行个人深入访谈，同时，在样本医院对 6 个实施临床路径管理的
3、科室进行医生意愿调查，根据访谈和医生意愿调查结果确定临床路径管理的主要环节，运用德尔菲法对 46 名专家进行三轮咨询，在主要环节中选出临床路径管理的关键环节；运用典型案例分析法分析样本医院关键环节控制方案及任务细分；在样本医院共收集 258 份阑尾炎患者病案首页和 259 份室间隔缺损患者病案首页，同时在开展临床路径管理的科1华中科技大学硕士学位论文室进行患者满意度调查，应用 SPSS12.0 统计软件对相关数据进行统计分析，得出临床路径管理关键环节控制效果并找出临床路径管理关键环节控制后存在的问题，针对问题提出相关的政策建议。结果1.临床路径管理现状和问题分析目前，临床路径管理在国外的研究与
4、应用基本处于成熟阶段。我国临床路径管理的效果在相关医院也得到验证，2009年起，临床路径试点工作将在我国全面展开。但专家咨询和关键知情人访谈结果显示，我国临床路径管理开展中尚存在一系列问题，包括：对实施临床路径管理的医院内外部条件认识不清；临床路径管理实施前准备工作不足；临床路径管理实施过程中职责不清；临床路径的评价标准不够确切和完善。2.临床路径管理关键环节确定在文献综述、个人深入访谈和医生意愿调查的基础上对实施临床路径管理的医院需要的条件、实施前需要做的准备工作、执行临床路径的过程中须考虑的问题和评价指标等方面进行分析，确定临床路径管理中主要环节，运用德尔菲法通过三轮专家咨询，在主要环节中
5、选出临床路径管理的关键环节。最终得出实施医院需要的条件、 实施前准备工作、执行中须考虑的问题和评价环节等4个第一层环节，30个第二层关键环节，同时，根据专家的意见，选出关键环节中五个主要关键环节，作为关键环节控制的重点，为关键环节控制策略的制定提供依据。3.临床路径管理关键环节控制策略研究者在既定关键环节的基础上，结合样本医院实际，运用典型案例分析法，在样本医院已有临床路径管理的基础上，制定临床路径管理关键环节控制方案，并协助医院管理者和相关人员将关键环节控制进行细化分析，使临床路径管理关键环节控制过程有据可依。4.临床路径管理关键环节控制策略应用效果分析收集甲、乙两家样本医院 258 例阑尾
6、炎患者和 259 例室间隔缺损患者效果评价的相关指标，进行实施临床路径管理关键环节控制效果分析。同时，选取开展临床路径关键环节控制的科室进行患者满意度调查。应用 T 检验、卡方检验对未实施关键环节2华中科技大学硕士学位论文控制和实施关键环节控制的患者的住院时间、住院总费用、药费、药品比和患者满意度情况等进行比较分析。结果显示，实施关键环节控制后阑尾炎患者的平均住院天数下降了 0.89 天，平均药费下降 504.74 元，药品比下降 14.09%；室间隔缺损患者平均住院天数减少 0.15 天，平均住院总费用下降 651.22 元。同时，实施关键环节控制后，患者对医院临床路径和对诊疗流程的满意度明
7、显提升，对整体医疗质量的满意度明显增加。应用多元线性回归对未实施关键环节控制和实施关键环节控制的患者的住院总费用的主要影响因素进行分析，结果显示，未实施临床路径关键环节控制的阑尾炎患者住院总费用的主要影响因素是药费、药品比、合并症数量；室间隔缺损的主要影响因素是药品比、药费、医疗保险参保情况、合并症的数量。实施关键环节控制后阑尾炎患者和室间隔缺损患者住院总费用的主要影响因素都是药费、药品比、住院天数。讨论与建议1.讨论1.1 临床路径管理关键环节分析研究者依据一定判断标准对已经确定的临床路径管理关键环节的重要性进行排序，得出路径的设计、诊断依据、病种的选择、医院领导的支持力度、结果的反馈与应用
8、五个环节为关键环节控制过程中最主要的关键环节。1.2 临床路径管理关键环节控制后相关指标变化样本医院依据关键环节控制的有关原则，为实施临床路径关键环节控制的患者制定了严格的时间流程表，提高了医务人员的工作效率，患者的平均住院天数明显减少。但是由于手术方式变更、年龄、病情复杂程度等因素导致阑尾炎患者实施关键环节控制后住院总费用略有增加；由于不合理用药现象依然存在、监督考核方案尚未完善等原因导致室间隔缺损患者药费略有上升、药品比明显增加。1.3 患者满意度分析由于临床路径管理关键环节的有效控制，促进了医患之间的交流和沟通，增进患者对医务人员的信任与理解，缓解了医患矛盾，问卷调查结果显示患者对医院整
9、体医疗质量的满意度明显增加。3华中科技大学硕士学位论文1.4 实施临床路径管理关键环节控制前后患者住院费用影响因素未实施关键环节控制与实施关键环节控制的患者的药费和药品比一直是影响住院总费用的主要影响因素，药品的合理使用成为控制患者住院总费用的重要举措。2.建议2.1 运用PDCA 循环模型促进临床路径管理关键环节控制将PDCA循环应用于临床路径关键环节控制中对于保持临床路径管理在医院长效开展、促进关键环节控制更加科学化、合理化具有重要意义2.2 针对重点关键环节促进临床路径管理持续改进运用六西格玛管理理论，促进临床路径管理关键环节控制的持续改进就要针对重点关键环节提出相关策略，做到严格路径设
10、计，确保临床路径文本的实用性；明确诊断依据，把好临床路径患者准入关；掌握病种选择原则，保证实施效果；提高领导支持力度，促进临床路径管理的良性循环；及时总结经验，注重结果反馈与应用。2.3 加大政府支持力度，促进长效机制形成国外实践证明，政府政策支持是临床路径管理能否有效开展的重要因素之一。由于我国临床路径管理现在正处于探索阶段，因此，政府要加强临床路径管理就要在现有临床路径管理经验的基础上，出台相关制度，确保临床路径管理的法律效力；建立适合临床路径开展的医疗费用补偿机制和医疗保险支付方式；加大财政投入力度，在全国范围内建立大规模一体化医院信息系统，促进临床路径管理长效机制的形成。关键词：临床路
11、径；关键环节；医疗质量；控制策略4华中科技大学硕士学位论文Study on Key Links and Control Strategy ofClinical Pathway ManagementCandidate : Guo ShuyanSupervisor: Tao HongbingABSTRACTAs a new kind of quality management mode, clinical pathway has great effect inimproving the quality of medical treatment, ensuring medical safety an
12、d reducing medicalcosts. Summarized the experience of clinical pathway in foreign country,we found that theclinical pathway management is a comprehensive system. It needs high levels ofmanagement techniques, advanced management concept, reasonable allocation of humanresources and supporting incentiv
13、e-restricted mechanisms in the hospital. At present, in theprocess of implementing clinical pathway,there are a series of problems such as themanagement concepts of hospital administrators fall behind, the infrastructure andinformation system of hospital is relatively backward, medical insurance mec
14、hanism is notsound, compensation mechanism of medical expenses is not supporting. The internaldynamics and external pressures are lack of clinical pathway management. Thedevelopment of clinical pathway in China can not reach the expectations and the model ofclinical pathway has not been widely used
15、in China.This study intends to explore the key links through the process of clinical pathwaymanagement, to analyse the problems and formulate effective control strategies. To analysisthe feasibility on the control of key links through the implementation effect in samplehospital.In order to provide t
16、heoretical and practical basis for the development of clinicalpathway management in Chinese hospital.Sources and MethodsBased on the qualitative and quantitative methods to determine the key links ofclinical pathway management by the Delphi method ;expert consultation; in-depthinterview and question
17、naire survey in sample hospital.To analyse the control plans and5华中科技大学硕士学位论文control programs using the analysis of typical case. To analyse the effect of the control ofkey links and find out the problems after control by the in-depth interview and the analysisof medical home.Results1 Analysis on th
18、e current situations and problems of clinical pathwayAt present,the research and application of clinical pathway management in foreign is inmature stage. The effect of implementation of clinical pathway in hospital is verified.Thepilot of clinical pathway will be in full swing in China from 2009. Th
19、e results of expertconsultation and key insider interview show there are still a series of problems on clinicalpathway.Such as the internal and external conditions of hospital is unclear;the preparatorywork before implementation is insufficient; the responsibility during the process ofimplementing i
20、s not clear and the evaluation criteria is not exactly and perfect.2 Determine the key links of clinical pathwayOn the basis of individual in-depth interviews and literature review,to analyse theconditions of the hospital that implement clinical path management; the preparatory workbefore the implem
21、entation needs to be done ; the problem must be considered in the processof conducting and evaluation indicator in order to ensure the main links of the clinicalpathways management. Selected the main part from the key links of clinical pathway bydelphi method. In conclusion, the qualification that t
22、he hospital must be required; thepreparing work before implementation; the issues must be considered in the execution andevaluation links were considered the first layer and there were 30 key links in the secondlayer.It is provided the basis for formulating the control strategy.3 The control strateg
23、y on key links of clinical pathwayOn the basis of the key links, the researchers assist the hospital administrators to refinethe key links combined with the actual situation of hospital. Using the analysis of a typicalcase, combined with the basis of clinical pathway management in sample hospital,de
24、termine the control program on the key links of clinical pathway management.4 Analysis on application effect of the control strategy on key links of clinical pathwayCollection assessing the effects of relevant indicators of 258 cases of appendicitis and259 cases of ventricular septal defect in A and
25、 B sample hospital. Meanwhile, carry out the6华中科技大学硕士学位论文surveys on patient satisfaction in the department that conduct the control strategy on keylinks of clinical pathway. The hospitalization days, total hospitalization expenses , drug cost,drug ratio, and patient satisfaction were compared before
26、 and after the implementation ofprocess control by using T test and chi-square test. The results showed that after theimplementation of process control; the average hospitalization days decreased 0.89 days;theaverage drug costs down 504.74 yuan and drug ratio fell 14.09% on the appendicitispatients;
27、 the average hospitalization days decreased 0.15 days; the average hospitalizationexpenses down 651.22 yuan on the patients of ventricular septal defect . Meanwhile, afterthe implementation of process control, the patients with the knowledge and understandingof the treatment process significantly en
28、hance, the satisfaction of medical quality increasedsignificantly.Analysis on the main factors of the total hospitalization expenses before and after theimplementation of process control by multiple linear regression. The results showed that themain factors of the total hospitalization expenses were
29、 drug cost, drug ratio and the numberof complications in patients with appendicitis; the main factors of ventricular septal defectwere drug ratio, drug cost, medical insurance and the number of complications beforeimplementation of process control.After the implementation of process control, the mai
30、nfactors of the total hospitalization expenses were all drug cost,.drug ratio, hospitalizationdays for the patients with ventricular septal defect and with appendicitis.Discussion and suggestionDiscussion1 Analysis on the key links of clinical pathwayBased on certain criteria, the researcher had bee
31、n established the order of the key linksjudging by the importance. The design of path, diagnostic evidence, the choice of disease,the support of leadership in hospital, feedback and application of the results were the mostimportant part of the process.2 Analysis on changes of relevant indexBased on
32、the relevant principles, sample hospitals formulated time flow sheet for thepatients, the efficiency of medical staff was improved, , the average hospitalization days ofpatients was decreased significantly. However, due to surgical changes, age, complications7华中科技大学硕士学位论文and other factors led to the
33、 the the total hospitalization expenses of patients withappendicitis increased slightly after implementation of process control; as irrational druguse still exist, supervision and evaluation programs had not improved led to the drug costsincreased slightly and the drug ratio increased significantly
34、in patients with ventricularseptal defect.3 Analysis on patient satisfactionAfter the process control, the exchange and communication between doctors andpatients were promoted, the trust and understanding was improved, the Doctor-PatientContradiction was eased, the patients awareness of the clinical
35、 pathway had significantlyenhanced, at the same time the medical quality satisfaction increased significantly.4 Factors of hospitalization expenses in the implementation of processThe drug cost and drug ratio were always the main factors of the total hospitalizationexpenses before and after the impl
36、ementation of process control,therefore, the rational useof drugs was an important measure to control the total total hospitalization expenses.Suggestion1 Using the model of PDCA cycle to promote the control of processThe PDCA cycle was applied to process control in the clinical pathway to maintainl
37、ong-term carrying out in the hospital and make the control of process more scientific andreasonable.2 Promot continuous improve on the control of processPromot continuous improvement on the control of process and make relevant controlstrategies.(a) be strict path design to ensure the practicality of
38、 the clinical path text; (b)cleardiagnosis to nail down patient access; (c)control the selection principle of diseases toensure the results of the implementation; (d)improve the support of leadership to formate avirtuous cycle of clinical path management;(e)sum up experience and pay attention toresu
39、lts-oriented feedback and application.3 Increase government support to formate long-term mechanismForeign proven, the support of government policies was an important factor canpromote the management of clinical pathway developing effectively. Government shouldunveil related systems to ensure the leg
40、al effect of clinical path management based on the8华中科技大学硕士学位论文existing experience; establish compensation for medical expenses and health insurancepayment system that carried out to clinical pathways; increasing financial investment,establish of large-scale integrated hospital information system in
41、 the nationwide, promoteto formate long-term mechanism on clinical pathway management.Key words: clinical pathway; key links; medical quality; control strategy9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： 年 月 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： 年 月 日 日期： 年 月 日
