門診就診流程品質: 臺大醫院總院內科部個案研究

Abstract

中央健康保險制度實施後，醫療產業競爭激烈，門診量有向大醫學中心集中的趨勢。本文以台大醫院總院內科部門診為個案研究，探討門診就診流程品質改進之道。 本研究由臺大醫院民國97年3月至8月之電腦資訊門診系統收集總院內科部門診各診次之開診時間、關診時間、掛號人數、實際看診人數等資料，計算並建立各診之延遲開診時間、總看診時間、平均每病人次看診時間、爽約人數、病人爽約率等流程變項資料庫，以卡方檢定及變異數分析探討醫師特質、門診時段對門診流程變項之影響，並探討各變項間彼此的相關。 分析結果顯示台大醫院總院內科部大部分醫師均準時或提前看診，僅有少數醫師延遲看診。內科部門診各變項的平均值為：延遲開診時間-2.1±24.6分，總看診時間240.2 ±64.4分鐘，掛號人數39.7±22.3人，實際看診病人數35.9±21.1人，每病人次看診時間9.3±9.4分，病人爽約率10.7±8.9%。以專任主治醫師、兼任主治醫師、或住院醫師的診次區分，兼任主治醫師延遲開診的較多，而專任主治醫師的診次病人數最多、總看診時間較長、平均每病人次看診時間較短、病人爽約率較低。 在138 位專任主治醫師中，平均開診時間延遲15分鐘以上的只有3位 (2.2%)；總看診時間超過240分的有64位 (46.4%)；平均實際看診人數在50人以上的有33位 (23.9%)；平均每病人次看診時間小於3分鐘的有3位 (2.2%)，介於3至5分鐘之間的有23位 (16.7%)；病人爽約率在15%以上的有23位 (16.7%)。 醫師次專科別會影響門診流程變項。與男醫師比較，女醫師提早開診的多、總看診時間較長、每病人次看診時間也較長。不同週間日的診次，門診就診流程變項會有不同。上午的診次掛號人數較多，但病人爽約率較高，實際看診人數及總看診時間上下午並無明顯相差，但平均每病人次看診時間下午診較長。 本研究發現醫師特質及門診時段會影響門診流程變項。內科部大多數醫師準時或提前開診，但掛號人數多、總看診時間長。與國內其他報告相較，臺大醫院內科部的平均每病人次看診時間在可接受的範圍內。但某些醫師的掛號人數近百，而病人實際看診時間偏短。本研究顯示依據總看診時間之長短調整上下午診次安排，可以增加診間利用。內科部門診病人爽約率偏高的問題，值得進一步探討。謹建議台大醫院院方針對少數醫師延遲開診、長期過量的門診負荷是否帶給醫護人員壓力，以及如何建立適當的掛號及爽約管理模式等議題，持續追蹤管理。

Since the implementation of National Health Insurance Program, competition within health care industry aggravated. To pursue good medical care quality, patients flowed to medical centers. Increasing amount of outpatients may jeopardize the quality of health care. This study evaluates the process quality of outpatient clinics in the Department of Internal Medicine, National Taiwan University Hospital. Administrative database during the period of March 2008 to August 2008 of the outpatient clinics in the Department of Internal Medicine, National Taiwan University Hospital were accessed through computer information system. Data of starting times, closing times, registered patient numbers, and visited patient numbers were collected. Process quality variables such as total time per clinic, average examine time per patient, and patient absence rate were calculated. Effects of physician characteristics and clinic characteristics on the process quality variables were analyzed by Chi-square test and Anova. Correlations between process quality variables were analyzed by Pearson’s correlation. Most of physicians attended their clinics on time or even earlier than schedule, only a few physicians delayed to start their clinics. The average process quality variables for the department were: delayed time -2.1±24.6 minutes, total time per clinic 240.2 ±64.4 minutes, registered patient number 39.7±22.3，visited patient number 35.9±21.1, average examine time per patient 9.3±9.4 minutes, patient absence rate 10.7±8.9%. Comparisons among the clinics responsible by full-time visiting staffs, part-time visiting staffs, and residents revealed that part-time visiting staffs were more frequent in delaying clinics, while full-time visiting staffs had most patient number, longest total time per clinic, shortest average examine time per patient, and lowest patient absence rate. Among 138 full-time visiting staffs, only 3 (2.2%) had average delayed time more than 15 minutes. Sixty-four physicians (46.4%) had average total time per clinic more than 240 minutes. Thirty-three physicians (23.9%) had average visited patient number more than 50. Three doctors (2.2%) had average examine time per patient shorter than 3 minutes, and 23 physicians (16.7%) had average examine time per patient between 3 to 5 minutes. Twenty-three doctors (16.7%) had patient absence rate over 15%. Physician specialty will affect the process quality variables. Comparing to male doctors, female doctors arrived clinics earlier, had longer total time per clinic, and longer examine time per patient. Clinics on different weekdays had difference in process quality variables. Clinics in the morning had more registered patient numbers but higher patient absence rates than clinics in the afternoon. The visited patient number and total time per clinic did not differ significantly between clinics in different daytime. However, the average examine time per patient was significantly longer in the afternoon clinics. Physician characteristics and clinic characteristics will affect the process quality variables. Delayed in starting clinics is not a major issue, while large patient amount and long total time per clinic deserve more concern. Comparing to other reports in Taiwan, the average examine time per patient seems to be acceptable. A few physicians had registered patient number around 100, their examine times per patient might be too short to satisfy patients’ need. Re-arrangement of the morning clinics with longer total time per clinic to afternoon may enhance utilization of the clinics space. The issue of high patient absence rate should be overlooked. This study suggests to monitor the process quality variables continuously, to evaluate the pressure of long-term high clinic loading to doctors and nurses, and to establish optimal registration model to minimize patient absence rate.