台灣醫院推行護理經理制度之研究

Abstract

順應健保給付制度的改變，護理專業常成為醫療機構變革的要角，俗說：「危機就是轉機」，目前護理人員不僅在醫院、社區或學校工作，也在健保局、醫療品質促進會、醫療評鑑團體擔任重要的角色。順應時勢，創造護理的新天地，是所有護理同業所共同關心的議題，也是本研究的主要動機。 本論文是透過台大醫院的經驗，探討台灣推行護理經理制的可行性與配套，護理經理制的構想，即是將病房管理的重責，包括臨床醫療資源、人力資源、單位預算與財務管理，責由護理經理統一運籌帷幄的變革計畫，對於傳統護理甚或醫療體系而言，將具有重大變革的意義。 在台大醫院2005年4月至2006年10月六個病房的經驗中，可以發現順利導入計劃的重要因素，除了高層主管的支持、協調，以及選取合適的單位進行試辦之外，為了補強對臨床照護品質的關注，有必要同時導入病患照護協調師的角色，同時還必須有持續的輔導與評值措施，始能隨時協助進行跨科部的協調、計畫的微調和修正。 本計劃推展的內容包括了病房成本管控、醫療資源中的藥物和昂貴的CT、MRI檢查的把關、病人住院與控床上的合作、人力資源管理以及照護品質的管理；雖然從病房的佔床率、平均住院率、病床週轉率等指標並沒有明顯的效益出現，但從外部顧客整體滿意度，以及內部顧客滿意度的調查中，可以發現已朝向正向回饋的趨勢。 不可諱言，台大醫院的護理經理制度試辦過程仍出現了角色混淆、人員壓力和支援系統不彰的情形，現有的成果僅能說是起步，尚無法論斷成敗，在試辦過程中發現需要進行的配套方案，包括主管決心與支持的展現、醫院組織架構的變革、教育訓練與合理的人力配置，以及建構完善的支援系統，有賴在未來進一步建立與調整。變革是持續不斷的創新與努力，護理人員要從中找到新的價值、新的定位與新的機會，就必須勇敢承受變革過程的短暫陣痛，這絕不是由上到下，幾位超級主管就可以主導，而是有賴全體護理人員的承諾與付出，期盼藉由本文，能成為改變的動力泉源，讓護理人員勇敢迎接變革，創造專業新的契機。

The change of NIH health services system. Nursing profession is playing an important role in the revolution of health institutions. As the saying goes “The best way to pass crisis is change”. Nurses not only working in hospitals, communities, schools, but also in NIH, JCHA take such an influencial role. In the generation of change, the nursing professions’ main issues concern the innovation of nursing. Nurse Manager is the revolution plan that could reorganize the management of clinical units. What’s more, Nurse managers response to health resources, human recourses, unit budget and financial management. The nurse manager strategy was applied to 6 units in NTUH since 2005 April to 2006 Oct as a pilot study. There were many main influencing factors of the project, such as the support and negotiation from the CEO, the appropriate rehearsal for each unit. Moreover, for the quality control of patient care, it is necessary to corporate with patient care coordinator. For the mean time, continuing consolation and evaluation is also important for the project. The main purpose of this project is to manage unit cost, prescriptions, unnecessary examination especially CT, MRI, length of stay, turn over rate, human resourcesness and care quality management. The result of this project shows positive feedback. Satisfactory rate are both high from inside and outside customers. However there is no obvious improvement in ratio of occupation, length of stay, turn-over rate. So far, nursing staffs have found the roles of nurse manager, patient care coordinator and head nurse confusing. Expressing stress and receiving enough support from others are the crucial to the project. It is hard to tell the outcome yet since it is just beginning. However, more accessory recourses should be built up and regulated, including the determination and support from the superiors, the revolution of the hospital’s organization, the man power of human resources and back up system. Change has to be constantly creative and self-evaluated. It is important to tell all nursing staffs that change is necessary for profession and mission. Of course, everyone has to pay for reaching the changing generation. It needs the commitment and effort from all nursing personnel. In viewing this project, I hope this is a reminder for all the nursing personnel to face the revolution.