運用時間導向之作業基礎成本制改善急診採檢流程之研究 ─以北部某地區醫院為例

Abstract

2019年底新冠肺炎疫情爆發以來對於國內醫療院所的來診量與營收造成的衝擊遠遠超過SARS時期。加上高齡少子化，中央健保局為了限制醫療費用的成長，導入總額預算以及疾病診斷關聯群，醫院在面臨給付不確定及醫療成本持續上漲的情況下，醫療院所應該更重視各種診療作業之成本的分析及管理。 本研究以北部某醫院急診室為例，以時間導向作業基礎成本制應用在新冠肺炎自費篩檢流程上。希望將服務費用更精準的分攤至各程序上，並能配合環境變化迅速對作業流程進行改善。 本研究將時間導向作業基礎成本制導入新冠肺炎自費篩檢流程，步驟一：透過會議制定出自費篩檢作業流程與相關工作人員。步驟二：藉由貼身觀察客戶自進入醫院到領取報告的過程，繪製出作業活動程序圖。步驟三：計算出每個參與者的成本動因費率。步驟四：以每個參與者在每個程序上花費的總時間乘以該參與者的成本動因費率，以獲得欲研究的服務流程的總成本。接下來透過精實六標準差DMAIC的分析，快速的判斷流程問題所在，提出改善之策略模式。 藉著精實概念有效減少流程中占大部份之無附加價值的等待時間，即病患等候開單、採檢和領取報告之時間。讓原本急診篩檢作業時間從原本的58.5分鐘，縮短至29分鐘。藉由專人專區等改善措施，作業活動成本從1539元減少為1060元，降低31%。醫材成本也從每人815元減少為491元，降低39.7%。 本研究證實時間導向作業基礎成本制能正確且即時的分攤成本至各項醫療程序上，並利用精實6標準差消除無附加價值之作業活動與提升流程效率。

Since the outbreak of the COVID-19 in the end of 2019, the decline of number of visits and revenues of medical institutions in Taiwan have far exceeded the SARS period. In cope with declining birth rate and aging population, the National Health Insurance Administration has introduced “global budgets payment system” and “diagnosis related groups” in order to limit the growth of medical expenses. In the face of uncertain payment and rising medical costs, medical institutions should pay more attention to cost analysis of various medical procedures. In this study, time-driven activity-based costing(TD-ABC)was applied to the self-paid screening process for COVID-19 in the emergency room of a northern hospital. Our aim is that the service cost can be allocated to the procedures more accurately, and the screening process can be quickly improved in accordance with the changes in the environment. In this study, TD-ABC was implemented to the self-paid screening process for COVID-19. Step 1: The screening process and related staff were formulated through the TD-ABC meeting. Step 2: A process map of the whole screening was developed by surveys and shadowing. Step 3: Calculate the Capacity Cost Rate(CCR)for each type of personnel. Step 4: Compute total service costs by multiplying resource capacity cost rate by process times & summing across whole screening process. Next, through the analysis of the Lean 6 Sigma with DMAIC, the problem of the process can be quickly found, and the strategy for improvement is proposed. Our study results showed: 1. Reduce the whole screening process time from 58.5 minutes to 29 minutes through extra-personnel in special area. 2. The cost of personnel was reduced from NTD 1539 to NTD 1060, a reduction of 31%. 3. The cost of medical materials has also been reduced from NTD 815 per person to NTD 491, a reduction of 39.7%. The Lean 6 Sigma reduces the waiting time, which accounts for most of the non-added value in the process, that is, the time for patients to wait for billing, inspection and receiving reports. This study proves that the TD-ABC can accurately and instantly allocate costs to various medical procedures, and use a Lean 6 Sigma to eliminate non-value-added activities and improve process efficiency.