台灣醫院推行品質改善專案後效應之探討

Abstract

背景與目的 品質改善專案在台灣的醫院行之有年，維持專案持續性效應是一大挑戰，尤其是在人員或組織變動的情境中。過去文獻顯示，即使專案後效應的特性及內涵有被討論，但僅止於概念性的描述，大多文獻對影響品質改善專案後效應的因素做探討，僅部份量測工具被開發，很少針對品質改善專案後效應的內涵來探討。本研究之主要目的為運用混合方法研究探討品質改善之專案後效應並試著建立概念性架構。研究架構分為三大部分，第一部分為探討品質改善專案後效應之潛在構面，第二部分為發展相關構面及組成的量表，第三部分為進行構面及組成項目的信效度驗證，同時提出品質改善之專案後效應模式架構 方法 本研究針對長期參與醫療品質獎主題類及突破品質系列之醫院，依醫院屬性及所在區域作立意取樣的篩選。參考整合推行架構，草擬訪談大綱，完成個人深度訪談及焦點團體座談會，並將訪談內容整理文字過程以NVivo作為輔助，除方便文字編碼與搜尋外，亦協助計算各因素之題目及次數，進而將概念做不同層次的因素歸類。接著透過密集的討論並參考相關文獻與模式，根據彙整之因素，發展為「「品質改善活動後效應維持之初擬概念模式」。接著則進行問卷的調查，以網路問卷方式收集問卷。結果計有21家醫院同意參與，回收450份有效問卷。接著以問卷結果進行探索因素分析、信度分析，檢視各量表之建構效度，以及使用因徑分析找出各影響因素間的直接與間間關係建構此理論模式。最後經專家會議討論後，修正並確認研究結果。 結果 本研究提出品質改善後效應模式的三個階段與九個構面，分別為階段一初始狀態(sustainability initiation)，此階段指的是品質改善活動結束後進入效果維持及執行單位的狀態，包括「品改活動特性」及「單位同仁特質」二個構面。階段二為效應維持(sustainability actions)，此階段指的是院方及單位維持效應的運作機制及相關的資源及人員情境因子，分別為院方維持機制的「系統支持」及執行單位的「日常管理」；影響維持機制的「內外資源改變」及「人員異動」，此階段各構面的互相作用是形成改善後效應的主要因子，同時亦是此模式的核心。階段三為改善後效應維持(sustainability impacts)的內涵，包括個人及組織層面的效益，短期對個人的「內外部顧客效益」即對病人及同仁的實質效益；中期促成組織調整的 「組織結構效益」即促成品質相關結構制度氛圍的形成，及長期的「組織成長效益」。最後，提出九個構面間不同構面間的十三個關聯性。 結論 本研究重要結論為品質改善後效應的內涵不只包含直接改善成效，更包含組織的成長與效益；品質改善後效應是經不同階段的構面互相作用而形成的；改善後效應的維持應考量情境變化；改善後效應的注重，可使品質專案改善模式更完整。

Background and Objective In Taiwan, quality improvement activities have been adopted by hospitals for many years. Quality improvement (QI) initiatives are a celebrated endeavor; however, sustainability is one of the major challenges. Sustainability refers to the holding the gains of a quality improvement project regardless of staff turnover or organizational change. It had been mentioned in previous studies that there was a limited concept exploration or instrument developed in relation to investigating sustainability of QI activity. The whole spectrum of after QI initiative implementation effect is not well defined. The purpose of this study is to develop a conceptual model for explaining the phenomenon of sustainability after quality improvement activities. Three major phases for this study are domain concepts and tentative model development, survey instrument development, and model validation. Methods A purposive sampling was used to select participating hospitals; as their previous HQIC performance, hospital accreditation level, and geographic location characteristics were used as the selection criterions. Both individual in-depth and focus group interviews were conducted using a semi-structured interview guides that focused on the sustainability phenomenon, its mechanism, barriers and facilitators. Interview audio files were transcribed verbatim and imported into NVivo qualitative software for primary data analysis. Once coding was completed, thematic analysis and inductive thematic analysis was used to identify themes and sub-themes. By way of intensive discussions and to-and-fro check from related references, the prototype of sustainability model was developed. There are 51 questions developed based on the five domains of sustainability effects. Internet survey was conducted after expert validity for the questionnaires. 450 questionnaires from 21 hospitals were collected. Exploratory factor analysis was done for checking construct validity. Chronbach’s alpha was done for internal consistence. Path analysis was major approach for model building to find all possible direct and indirect relationship among those construct or variables. Results Regarding the quality improvement sustainability model, three phase of sustainability initiation, sustainability actions, and sustainability impacts were proposed. There are two, four and three dimensions in each phase, respectively. In the sustainability impacts, there are the short-term effect of “internal and external customer effect”, mid-term effect of “organizational structural effect” and long-term effect of “organizational growth effect”. Moreover, thirteen research hypotheses from empirical data testing were shown the interrelationship among dimensions. Conclusion The sustainability of quality improvement initiatives is a complicated process which involves timely adaptation to an environmental change. The comprehensive framework of quality improvement sustainability model can fulfill the quality improvement process and assure the achievement from the quality interventions. Especially, the mechanism or actions from this study provide the practical approaches to maintain the sustainability of QI projects