醫院評鑑對醫院產生預期與非預期效果之初探

Abstract

目的：近年來醫院勞動結構改變，醫院病人安全面臨諸多風險及挑戰，包含醫護人力流失，醫事人員壓力負荷，醫院暴力及急診塞車…等等。在過去文獻中甚少在醫院評鑑過程對評鑑利害關係人，所造成預期及非預期之效果進行質性之探討。本論文研究目的為：(1)透過文獻收集，瞭解過去醫院評鑑產生何種效果及採用研究方法與研究對象；(2) 醫院評鑑影響效果探討：藉由訪談探索醫院評鑑關係人對醫院評鑑效果如何產生，何時發生的陳述及補強文獻內容的不足。(3) 醫院評鑑預期與非預期效果初探：綜整醫院評鑑關係人陳述與建議，並透過文獻驗證，作為未來衛生政策及醫院評鑑的改善參考。 研究方法：本研究以「文獻回顧」、「深度訪談」、「焦點團體訪談」作為研究方法。本研究透過質性訪談方式，以初擬訪談大綱進行醫院評鑑利害關係人訪談收集資料，研究對象分成四組：(1)醫院業務承辦人、(2)醫院單位主管、(3)醫院評鑑委員、(4)醫策會工作人員；採用二種訪談方式進行：(1) 醫院評鑑評審委員及醫策會評鑑工作人員採深度訪談，醫院評鑑準備業務承辦人及醫院評鑑受評單位主管採焦點團體訪談。以Nvivo軟體資料分析，採用編碼去連結進行訊息歸類，並從中整理結果與研究目的呼應。 研究結果：32名研究參與者包含醫策會工作人員6名、醫院評鑑委員5名、承辦人員8名、醫院評鑑受評單位主管13名。研究結果發現，受訪人員大都肯定醫院評鑑在外部專家提供意見、團隊合作與分工、病人安全與權益、(照護)品質及改善等方面所帶來預期的效果。然而醫院評鑑準備會產生壓力，過多文書作業及長官給予的壓力都可能造成人員離職(離退)的非預期效果。對於醫院評鑑多數人採肯定的看法，正向影響大於負面的效應，為降低評鑑壓力，醫院長官應對參與評鑑人員適度關心，對於付出的努力予以支持。 結論：參與評鑑人員熬夜加班投入無形成本，希望獲得主管支持，醫院經營者能真正感受員工工作負荷，並提供必要協助，才能讓醫院職場工作環境獲得改善。醫策會工作人員及醫院評鑑委員可能面對受評單位回饋時，接受情緒上的變化而有壓力產生，希望能獲得必要協助及支持。醫院評鑑在文獻發現會對準備評鑑人員產生壓力，牽動醫療機構人員工作意向，也關係醫療照護品質及病人安全，希望政府衛生單位能正視醫院評鑑可能產生非預期效果，以進行研擬相關因應對策。

Background and Objective: The structural changes of hospital labor in recent years have brought many risks and challenges to patient safety in hospitals, including doctor and nurse shortages, work-related stress, hospital violence, and overcrowding of emergency department, etc. Past studies rarely explored the anticipated and unanticipated effect of hospital accreditation process on its stakeholders from a qualitative approach. The objectives of this study are: (1) to understand what the effects of past hospital accreditation and the use of research methods and study through literature review; (2) to investigate the effect of hospital accreditation: through interviews to explore the relationship between stakeholders and their effect on hospital accreditation, reinforcing current literature contents, and (3) to organize the hospital accreditation stakeholders statements and recommendations, and verify through literature as to improve future health policy and hospital accreditation of reference proposal. Methods: This study used “literature review”, “in-depth interviews”, and “focus group interviews” as the core methods. Using qualitative interviews, a preliminary set of questions was drafted to collect data from stakeholders. Research subjects were divided into four groups: (1) hospital staffs handling accreditation, (2) hospital supervisors handling accreditation, (3) accreditation surveyors, and (4) staffs from the Joint Commission of Taiwan. The interviews were conducted in two ways; in-depth interviews were used for the accreditation surveyors and staffs from the Joint Commission of Taiwan, whereas focus group interviews were used for hospital staffs and hospital supervisors. Data was analyzed using coding to connect and categorize information in Nvivo software, corresponding the results to research objectives. Results: A total of 32 subjects participated in the study, including 6 staffs from the Joint Commission of Taiwan, 5 accreditation surveyors, 8 staffs handling hospital accreditation, and 13 supervisors handling hospital accreditation. Results showed that most subjects agreed on the intended effectiveness of hospital accreditation process on external expert feedback, teamwork, delegation, patient safety and rights, quality care and improvement, etc. However, the accreditation process also caused stress to workers by adding additional administrative paper work and pressure from supervisors, leading to unintended consequences like employee turnovers. Majority of the subjects had a positive view on the accreditation process, believing its positive effects outweighs the negatives. To decrease its resulting stress on workers, supervisors should be more supportive of participants. Conclusion: Overtime work invested by participants of the accreditation process are intangible assets. With supervisors’ support, hospital managers may better understand workers’ work load in order to provide necessary support for improving the hospital work environment. Joint commission staffs and surveyors should also receive support and assistance to cope with the emotional changes and stress from facing feedback from the medical institution staffs. Hospital accreditation in the literatures showed that accreditation stress, affects hospital staff wishes to remain, will also affect the quality of health care and patient safety. Government health administrative agencies should address hospital accreditation may have unintended effects for elaboration related to related countermeasures.