以KANO二維模式探討大台北地區血液透析病患就醫行為

Abstract

透析治療是末期腎衰竭病患維持生命的重要治療方式。血液透析患者的特質和治療模式具有其獨特性，因此在其就醫行為上，包括醫療院所的選擇，對於洗腎治療的需求、期望與滿意程度等，勢必有其不同的認知與考量。洗腎醫療院所彼此之間競爭激烈，卻又受限於逐年下降的健保費用給付，在面臨資源有限而病人需求多面，卻又不可能做到面面俱到的情況下，該如何區別不同洗腎患者的主客觀需求、偏好與考量，把有限的資源做最有效率的分配？ 在競爭策略上，差異化成功的關鍵在於了解顧客的要求與偏好；而成功的差異化必須要將客戶差異化的需求與企業組織差異化的能力相互配合。Kano二維品質模式運用於醫療服務上，可以將病患的心聲分類，幫助醫療機構辨識及判斷。本研究透過Kano二維模式，分析在不同層級透析院所就醫的病患，對於洗腎醫療服務的品質認知與滿意度，以及對於其就醫行為的影響。並以病患的偏好和特質，分析其在透析醫療服務流程中各種不同構面的需求，探討影響其就醫行為的確切因素。希望找出在透析醫療服務流程中，何種服務品質要素具有為病患帶來價值的潛力，提供洗腎醫療機構作為參考，讓不同透析院所能夠根據院所本身的優、劣勢，考量未來環境的變化與競爭對手的行動等來分配資源，選擇適當的競爭策略。 本研究以大台北地區血液透析病患為抽樣對象。採用自擬的結構式問卷，以「床邊問卷訪談」之方式，針對不同層級透析院所共320位病患進行隨機抽樣調查。所有的資料來源皆為初期資料。有效問卷共300份，回收率93.8％。透過問卷調查病患對於透析醫療服務流程的品質要素分類認知、就醫滿意度、以及人口學資料。並以卡方檢定、變異數分析、與事後多重比較等統計方法進行分析。 研究結果顯示，血液透析病患對於透析院所提供的醫療服務，在「結構」、「過程」、與「結果」的服務品質構面當中，各有不同的品質特性歸類。部份品質項目具有二維的特性，但大部分仍為一元屬性。不同層級透析院所的病患，對於利用Kano品質特性歸納的服務品質認知，存在著顯著差異。而影響病患對於品質服務要素的分類認知的最主要因素，除了是「不同透析院所的層級」外，「往返交通耗時」的多少具有決定性的關鍵。病患對於其現有就醫院所的服務品質滿意度表現，基層院所病患對於結構面的滿意度較低，而醫學中心病患則是較不滿意結果面。而病患對於Kano二維品質的不同認知會影響其滿意度。 病患因其主客觀條件上獨特的認知、需求與考量，選擇了不同層級的透析院所就醫，而不同層級院所的病患對於其所選擇的院所，也仍然存在著不同類別與項目差異化之未被滿足的期待與需求！所以存在於病患的就醫行為與認知之間的差異，正是透析院所可以加強改善的著力之處。透析院所可以透過Kano模式的服務品質認知結果，結合病患的滿意度評估指標，透過適當的資源配置，來加強鞏固一元品質與魅力品質作為提升滿意度的依據，並且留心確保當然品質以減少不滿意度。同時更可以透過Kano二維模式的品質生命週期，創造透析院所的可獲利差異化之競爭優勢。

Dialysis therapy is important and necessary for uremia patients to prolong their lives. Because of the uniqueness of treatment and patient characteristics, hemodialysis patients have different perceptions and considerations on their medical care seeking behavior. The behavior includes the choice of medical institution; the special needs; expectations and satisfaction of dialysis treatment. Nevertheless, not only the competitions among dialysis facilities have become more intense after global budget system implemented, but also the reimbursements of health insurance have been cut down yearly. Therefore, all the dialysis facilities face the difficult challenge, i.e., how to prioritize the service quality expectations of their patients? Moreover, how to effectively allocate limited resources to meet the specific needs of patients? The efficient management for corporate to take competitive advantages by applying strategy of differentiation was based on the association of corporate core complement and resource to the differentiation of customers’ actual need. Kano’s model had been applied in medical service industries to recognize the needs and expectations of patients. Hence, this study was using Kano’s model to identify the factors which affected the perceptions and considerations on medical seeking behavior of hemodialysis patients. Also the relationship between patient satisfaction and patient demographics, patient characteristics had been explored among various medical facilities. Furthermore, it was expected to establish a well-constructed evaluation instrument to appropriately evaluate the quality of medical service during dialysis therapy process through this study. This was a cross-sectional study. 300 completed personal interview surveys from 320 hemodialysis patients in the Taipei metropolitan area were collected. These surveys were investigated with a structured, closed and self-designed questionnaire. Chi-square, analysis of variance, and post hoc comparisons were also employed. The results revealed that 1) the quality properties of hemodialysis medical service and quality elements could be identified by using Kano’s model. 2) there were statistically significant differences among the hemodialysis patients at different levels of dialysis facilities on the assessment of the service quality elements. 3) in addition to the different levels of dialysis facilities, traveling time was also an important effective factor on the assessment of service quality elements in hemodialysis patients. 4) patients at different levels of dialysis facilities had significant differences on the satisfaction with the quality of dialysis service. And 5) Kano’s two-dimensional quality had influence on the satisfaction of dialysis patients. Dividing the dialysis service items into quality elements in accordance with Kano’s model could provide more evident direction for the executives of dialysis facilities to improve patient satisfaction and to enhance dialysis service.