平衡計分卡在肝癌的應用: 以南部一區域教學醫院為例

Abstract

肝病是國病，肝癌更是十大癌症死因之第二名。以2013年為例，肝和肝內膽管癌死亡人數為肝癌8217人。此外，該年度亦有4843人因慢性肝病死亡。總計台灣一年約有一萬三千人死於肝病。個案醫院所處的雲嘉縣市，屬肝癌高發生率與死亡率地區。在肝病的臨床處理上，除了肝膽科醫師外，亦橫跨了一般外科、影像醫學科、放射腫瘤科、腫瘤科、病理科等，因此跨科別團隊的合作，在肝癌的處理上益形重要。 平衡計分卡是由柯普朗與諾頓所共同發展出來績效衡量系統，不僅強調績效的評估要在財務、顧客、流程、學習與成長四個構面間達到平衡，更進而把它當成策略管理及組織溝通的工具，以達成組織願景；是醫療機構一項很好的管理工具。 個案醫院為區域教學醫院，其經營宗旨為「守護生命，守護健康，守護愛」，也提出其願景為：1.加強資源整合達到永續經營的目的、2.提供全人全程的卓越醫療品質，成為雲嘉最被信賴的醫院、3.樹立人本醫療的典範。為實現醫院的願景，醫院在2013年導入平衡計分卡，並選定肝癌作為肝癌團隊執行的目標之一。團隊在管理專家的協助下，從資料蒐集，文獻探討，肝癌實證醫學的論證，使用SWOT分析團隊所處的位置，進而擬定肝癌策略地圖，計有策略一：建立權威性之醫療、策略二：建立全人全程的人本醫療典範、策略三：建立社區醫療之服務模式、策略四:強化資源與資訊系統整合，以提升營運與成本管理效率；並擬定關鍵衡量指標內容，目標值與行動方案。並適時開始執行。總計在財務構面有2項指標，病人構面有7項指標、流程構面有13 項指標、學習與成長構面有3項指標。經過一年的調整，約有86.4％指標達成或部分達成，但團隊發現有些關鍵衡量指標並不關鍵；有些收集困難，亦無法量化，也將於年度平衡計分卡會議建議修正刪除。 平衡計分卡的成功要素文獻有諸多探討，對肝癌以平衡計分卡在本院實施而言，確實可讓團隊用較寬廣的心來面對與處理跨科醫療或跨醫療與非醫療或跨團隊事務，初不習慣，進而逐漸孰悉；而依作者而言，平衡計分卡欲成功，領導者的親身參與，上下協調人力、設備與資訊的到位，團隊成員共識及現有評估制度的連結是重要的關鍵因素。

Liver disease is the “national” disease of Taiwan. Hepatocellular carcinoma ranks second in deaths caused by malignancies in Taiwan. In 2013, for example, there are 8217 deaths due to liver and intrahepatic bile duct cancers. In addition, 4843 people died from chronic liver disease in the same year. A total of about thirteen thousand people die from liver disease per year. The “case” hospital in discussion is located in Yunlin-Chiayi area, where a high incidence and mortality rate of liver cancer had been observed. In the clinical management of liver disease, the physician specialist in hepatobiliary diseases often needs the joint participation of specialists from general surgery, interventional radiology, radiation therapy, oncology, and pathology. Good teamwork across these disciplines is the most important factor in the successful treatment of liver cancer. Balanced Scorecard, jointly developed by Kaplan & Norton, is a performance measurement system that stresses the balance of assessment among the four perspectives, namely financial, customer, business processes, and learning and growth. In turn it can be used as policy management and organizational communication tools to achieve organizational vision. Thus it is also a very good medical management tool. The “case” hospital is a regional teaching hospital. She strives to be 'the guardian of life, the guardian of health, and the guardian of love'. Her visions are: 1. integration of resources to achieve the objective of sustainable operation; 2. provision of excellent quality of medical care for the whole person, becoming the most trusted hospital in Yunlin and Chiayi counties; 3. becoming the model of humanistic medical care. To achieve these visions, the hospital adopted the Balanced Scorecard in 2013 and selected liver cancer as the leading practice model. A special team was formed, and, with the assistance of management experts, started to collect data, explore the literature, extract evidence-based medicine for liver cancer treatment, and use SWOT analysis to develop liver cancer strategy map. Four strategies were named: I: the establishment of an authoritative medical care system; II: the establishment of a humanistic medical care model; III: the establishment of a community health service model; and IV: strengthening integration of resources and information systems, in order to enhance operational efficiency and cost management. The BSC team then developed key performance indicators, target measures and action plans. The BSC program was timely executed. In summary, there are two indicators in financial perspective, seven indicators in patients’ perspective, thirteen indicators in internal business process perspective, and three indicators in learning and growth perspective. After a year of execution, 86.4 percent of KPI was achieved or partially achieved, but the team found that some KPIs are not critical; some are difficult to collect; some cannot be quantified. These KPIs will be proposed to be deleted in the BSC annual meeting. Factors of success have been discussed in the Balanced Scorecard literature. The implementation of the Balanced Scorecard in liver cancer management in our hospital did broaden the team's views in dealing with affairs among different specialties, and between medical and non-medical caregivers. In the beginning, members of the team were not comfortable with scorecard because of the unfamiliarity, but gradually everyone learned. The author feels that, to be successful in applying Balanced Scorecard to the management of clinical problem, a good leadership, adequate supply of manpower, equipment and information technology, fair team consensus, and seamless connectivity with the existing assessment system are essential.