农村地区乡镇卫生院绩效评价研究
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摘要
研究目的
随着政府不断加大对农村卫生的投入,如何评价和监管乡镇卫生院的绩效,以促进其卫生服务质量、服务效率和成本效果不断提升成为亟待解决的难题,而绩效评价被认为是有效监督和管理医疗卫生机构的科学方法之一。本研究的目的是在综合分析国内外卫生机构和卫生系统绩效评价实践和理论的基础上,构建具有一定前瞻性的乡镇卫生院绩效评价理论框架,并在此基础上经过系列理论和实践研究,研制一套系统的乡镇卫生院绩效评价指标体系。为乡镇卫生院和各级卫生管理人员评价乡镇卫生院的绩效提供理论和实践经验,为政府监管农村卫生提供依据和政策建议。
研究方法
本研究运用卫生经济学、卫生统计学和社会医学的理论和方法,采用主客观相结合的方式,探索我国乡镇卫生院绩效评价的理论和方法。主要研究方法包括:1、构建绩效评价理论框架和绩效指标筛选方法包括:(1)文献荟萃法;(2)专家咨询法;(3)变异系数法;(4)假设检验法;(5)主客观交叉验证方法。2、指标权重的确定方法包括:(1)基于“功能驱动”原理的主观赋权法;(2)基于“差异驱动”原理的客观赋权法;(3)综合集成赋权法。3、绩效评价指标的信度和效度检验法:内评和外评交叉验证法,用Spearman等级相关检验两种方法评价结果的一致性,检验指标体系的效度,利用SPSS的信度检验模块,检验指标体系的信度。
研究结果
通过系统总结国内外卫生机构绩效评价方法和理论,紧扣我国卫生体制改革趋势和乡镇卫生院的功能定位,在多轮专家研讨和现场实证研究的基础上,取得以下研究结果:(1)对绩效理论进行深入分析并界定了乡镇卫生院的绩效。首先绩效有不同层次之分,乡镇卫生院绩效是指组织机构的绩效;其次绩效是多维的而非单维的,它是一个综合性的范畴;再次,绩效有价值取向,不仅体现在投入产出的效率,也体现以人为本和社会责任的价值;最后乡镇卫生院绩效应充分反映其“六位一体”功能和服务本质。在此基础上提出乡镇卫生院的绩效:在“人人享有基本卫生保健”和“六位一体功能”的发展理念下,以一定的质量保证、以“患者为中心”、利用各种社会资源获得卫生服务产出和有效改善居民健康程度的最大化。(2)绩效评价方法已进入绩效评价指标体系的创新时期,本研究借鉴和利用了这一时期较为成熟方法,将平衡记分卡的思想和关键绩效指标体系的思想进行融合,形成我国农村地区乡镇卫生院绩效评价指标体系构建的基本理论体系。在绩效评价实践方面,我国基层卫生机构绩效评价处在起步阶段,还缺乏一套科学系统的绩效评价方案。(3)构建六维度的乡镇卫生院绩效评价理论框架:服务效率、人均受益量、成本效果、服务质量、功能体现和发展潜力;(4)研制出一级指标6个、二级指标17个、三级指标78个的乡镇卫生院绩效评价指标体系,通过主观、客观和综合集成赋权法确定了指标的权重系数,其中一级指标的权重分别是:服务效率为0.20、人均受益量为0.15、成本效果为0.10、服务质量为0.25、功能体现为0.20,发展潜力为0.10。(5)构建“标准服务量”作为测算乡镇卫生院服务产出的单位,并把乡镇卫生院的各项服务按技术含量、劳动强度、服务风险三个因素折合成“标准服务量”的值,由此研究出测算乡镇卫生院服务产出的方法。同时确定乡镇卫生院投入成本包括四个方面:政府投入、机构自身投入、固定资产折旧和人力资源投入。由此可以测算乡镇卫生院的服务效率。(6)构建“居民健康指数”测算乡镇卫生院的服务效果。并确定法定传染病发病率、婴儿死亡率、高血压患者脑卒中发生率、EPI相关疾病发病率、高血压控制率和孕产妇死亡率作为测量辖区内居民健康水平的敏感指标,构建加权综合测量模型计算“居民健康指数”,由此可以计算乡镇卫生院的成本效果。构造其他“复合性指标”如机构投入、服务质量等并提出相应的测量方法;(7)对乡镇卫生院绩效评价指标体系效度和信度检验结果:内外交叉检验,对两组结果做Spearman等级相关统计分析,相关系数Rs=0.78(P<0.05),结果具有统计学意义,说明指标体系具有较好的效度。二级和三级指标体系克朗巴哈系数a标准值分别是:0.9012和0.8642,说明指标体系信度较好。(8)在指标体系研究的基础上制定乡镇卫生院绩效数据过录表,经信度和效度检验后,于2006年和2007年分别到青海和重庆做乡镇卫生院绩效评价。应用结果表明各地乡镇卫生院在服务效率、服务质量、人均收益量方面有明显的差异,普遍存在效率低下、服务质量差、农村居民对乡镇卫生院的服务利用不足等现象,部分乡镇卫生院没有很好履行“六位一体”的服务功能,以人为本的服务理念还需在过程服务中进一步加强。
研究结论
绩效评价是运用一定的评价方法、量化指标及评价标准,对组织为实现其职能所确定的绩效目标的实现程度,及为实现这一目标所安排预算的执行结果所进行的综合性评价。通过本项目系统研究,基本结论如下:
1、界定乡镇卫生院的绩效对乡镇卫生院而言,其绩效是在“人人享有基本卫生保健”和“六位一体功能”的发展理念下,以一定的质量保证、以“患者为中心”、利用各种社会资源获得卫生服务产出和有效改善居民健康程度的最大化。此概念反映了乡镇卫生院的服务本质和历史使命,具有一定的前瞻性。
2、乡镇卫生院的绩效评价理论框架乡镇卫生院绩效评价理论强调基层卫生机构的服务本质和社会功能。从投入、产出、质量、效率、效果和发展潜力等方面综合考虑,构建乡镇卫生院绩效评价理论框架。该理论框架丰富和发展了绩效评价理论体系。
3、研制乡镇卫生院绩效评价指标体系在乡镇卫生院绩效评价理论基础上,通过专家讨论和现场实证研究法,提出了一套乡镇卫生院绩效评价指标体系。研制的指标体系具有系统性、可行性和真实性。
4、基于“功能驱动”和“差异驱动”原理的主客观赋权法,并结合综合集成赋权法确定了指标的权重系数,赋权方法比较合理。
5、通过构建“标准服务量”、健康指数等复合指标,并提出相应的测量方法,为评价机构的效率和成本效果提供科学的测量方法,解决了绩效评价中技术难题。
6、通过内部和外部评价比较,多轮的现场实证研究,评价结果与卫生行政部门掌握的情况基本一致,同时指标体系重复度量效果较好,说明研制的乡镇卫生院绩效评价指标体系具有较好的效度和信度。
7、研究得出的乡镇卫生院绩效评价指标体系能从深层次、从量化角度比较不同乡镇卫生院绩效的优劣和绩效影响因素,对提高卫生行政部门的监管手段、促进乡镇卫生院又好又快发展具有重要的指导和实践意义。
研究创新
1、探索和完善了绩效和绩效评价理论
自世界卫生组织2000年发布191个成员国卫生系统绩效以来,国内外研究学者从不同角度、针对不同卫生体系做了进一步探索性研究,但对乡镇卫生院的绩效和绩效评价研究较少。本研究利用公共卫生机构绩效理论,立足政府外评的角度,结合基层卫生服务机构的职责和功能定位,追求以人为本和构建和谐社会的价值取向,提出乡镇卫生院的绩效是以一定的质量保证、以“患者为中心”、利用各种社会资源获得卫生服务产出和有效改善居民健康程度的最大化。乡镇卫生院绩效评价理论突出强调其服务本质和社会功能。从投入、产出、质量、效率、效果和发展潜力等方面综合考虑,构建乡镇卫生院绩效评价理论框架。
2、创建了卫生服务测量方法——标准服务量
镇卫生院的服务产出比较复杂,各种服务之间可比性差。国内外研究者对服务量的核算主要是以服务时间和服务成本为基本依据,但没有凸现卫生服务的本质,即技术含量、劳动强度和服务风险等因素。本研究在他人研究的基础上,提出从服务的技术含量、劳动强度和服务风险等因素综合衡量基层卫生机构的服务产出。首先界定“标准服务量”的内涵,利用专家法和现场实证法,确定其他各项服务的“标准服务量”的相对值。解决了镇卫生院服务量的测量理论和技术难题。
3、构建了新的复合性指标
在具体测算绩效各维度的方法上,突破过去以定性描述为主的方法局限,建立了新的综合性指标,利用“综合健康指数”测量居民健康效果,用于衡量某区域内居民总体健康水平的指标;“机构投入”反映了一定时期内机构消耗的社会资源;“服务质量”反映了机构的技术质量、非技术质量和居民满意度等;实现了镇卫生院成本投入“货币化”的测算办法等。最后通过数学模型测算出乡镇卫生院绩效具体得分。
Objectives
With the more and more health resources being put into the rural area from the government continuously,it is the problem needed to be solved that how to improve and increase the health service quality,efficiency and cost - effectiveness of THCs. As a scientific method, performance assessment has been widely and effectively used to supervise and administrate health service organizations.
This study was aimed to use a serise of theoretic analysis and practical research to build up the performance evaluation theoretical framework and indicators system of THCs based on reviewing the literatures at home and abroad. Then provide some evidence for the government to implement the performance assessing, and also help the health administrators and researchers correctly evaluate the performance and quality of THCs so as to develop reasonable strategies suggestions in improving THCs performance.
Methods
In this study,lots of theories and methods were used from health economics,health statistics,social medical and health manangement,and based on objective and subjective assessment methods to explore the theory and methods of performance evaluation of THC in rural area. Main methods such as: 1.the research methods of performance evaluation theoretical framework and indictors were: (1) Literature searching ;(2)Experts discussion and Delphi method;(3) Variation coefficient method;(4) Hypothesis test;(5) The cross verification of objective and subjective assessment method.2. The method of computing the indicators weight including: (1) Subjective principle of the function’s drive; (2)Objective principle of the difference’s drive;(3)The comprehensive principle on the weight coefficient. 3.The methods of reliability and validity test of indictors system are Spearman rank correlation test method and Cronbach’s alpha coefficient test way.
Results
By systematical summing-up and comparing the performance evaluation methods and theories of domestic and overseas,focusing on rural health system reform trend and THC’s functional orientation,and through experts discussion and empirical research,the results of this study are as follows: (1)Some relevant performance theory analyzed deeply and put forward the conceptation of THC performance.Firstly, performance is described in different levels by systems,organizations and individual,and THC performance belongs to organizations;Secondly,performance is multiple dimensions,bu not a single one,it’s a comprehensive concept;Thirdly,it has Value Orientation,not only embodies the input-output efficiency, but the value of“Human-Oriented”and social responsibilities;Finally,THC performance should reflcet fully the function of“six-in- one”and service responsibility. On these theoretical analysis, the concepts of performance of THC is making full use of social resources to health service maximization and improves people’s health status obviously, under the development idea of“Health for all”and "six-in-one ", center on patients, guarantee the quality of health service. This concept is prospective,and reflects the essence and historical mission of THCs in our country. (2) The of methods performance evaluation have developed to the innovation term of indicators system,and then absorbs and utilizes these mature methods, integrates the balanced scorecard(BSC)and Key performance indicators(KPI). In the end, we formed the theoretical system of THC performance evaluation in rural area.In the performance evaluation practice, the research and utilization of performance appraisal is still in its Starting period in primary health organizations,there is no scientific and systematic program of performance evaluation for THCs.(3)Having constructed the dimensions of performance assessment which contains six aspects,such as service efficiency, the quantity per person enjoys, the cost-effectiveness, the realization of function, the quality of service and the development potential in the THCs.(4)Building up THC performance evaluation indicators system,which composes of 6 first class indictors, 17 second class and 78 third class indictors.The weight coefficients of the three-level indicators were calculated by subjective principle of the function’s drive,objective principle of the difference’s drive and the comprehensive principle.The weight of 6 indicators of the first class are 0.20,0.15,0..10,0.25,0.20,0.10.(5) "The standard service unit”was chosen as the smallest unit to measure the quantity of health service provided by THCs.Then, all the service items were transformed to the standard quantity of "the standard service unit”based on technical content, labor intensity and risk degree. On the other hand,the input of THC includes: government input, self-investment, depreciation of fixed assets and capital and human resource.Then we explored the method of measure the economic efficiency of THCs.(6) Creating the new comprehensive indicators—"The comprehensive health index" reflects the entirety health state of population,the indicators of the incidence of legal infections, the infant mortality rate, stroke incidence of patients with hypertension,the incidengces of EPI related diseases,the control rate of patients with hypertension and maternal mortality were selected to measure the health status for residents.and other complex indicaors as“the quality of service " reflects the technical quality, non-technical quality and satisfaction of patients and so on. (7)The reliability and validity of indictors system: Spearman ranking correlation coefficient is 0.78(P<0.05),and Cronbach’s alpha are 0.9012 and 0.8642 of the second class indictors and the third class indictors,it was showed that the reliability and validity of the indicators system is very good. (8)We made the questionnaires of THCs performance on the based of the indicators system.By the reliability and validity tested, had done the fields survey appraisal of THCs in 2006 an 2007 in Qinghai Province and Chongqing.The results showed there had obvious difference in service efficiency, cost-effectiveness,and service quality in THCs in different area, and low efficiency,low service quality and insufficient utilization of health services in rural areas are very common. Some THCs can not fulfill the function of“six-in-one”, the service idea of“human-oriented”must be strengthened in work.
Conclusions
Based on the results of the research,the conclusions and recommendations could be put forward.(1) The concepts of performance of THC is making full use of social resources to health service maximization and improves people’s health status obviously, under the development idea of“Health for all”and "six-in-one ", center on patients, guarantee the quality of health service. This concept is prospective,and reflects the essence and historical mission of THCs in our country. (2)Based on the service functions and social functions of THCs,the theorical framewark of perforamce evaluation of THC has six dimensions: service efficiency, the quantity per person enjoys, the cost-effectiveness, the realization of function, the quality of service and the development potential.This theorical framewark enrichs and develops the perforamce evaluation theorical system.(3) The performance evaluation indicators system is set up surrounding firmly the performance evaluation theory and function positioning of THC.The whole indicators system is valid,feasible and realible.(4)The weight coefficient of the three-level indicators is based on subjective principle of the function’s drive, objective principle of the difference’s drive and the comprehensive principle on the weight coefficient.These methods were reasonable.(5) By composing "the standard service unit”and“The comprehensive health index”,then forming the revelant measurement methods,it solved the technical problems about appraisal methods of efficiency and cost-effective.(6) Through compared evaluation, more times verified in fields and Cronbach’s alpha coefficient tested,the result demonstrates that the performance indicator system is steady, practicable and has good reliability and validity.(7) From the perspective of the government, this performance evaluating indicators system could systematically disclose that in what level the Township Health Centers, could provide some good advice for the government to implement the performance assessing, and also help the health administrators and researchers correctly evaluate the performance and quality of the organizations so as to develop reasonable strategies suggestions in improving the THC’s performance.
Innovation
1.Explored and improved the performance and performance evaluation theories
From WHO promulgating the health system performance of 191 member countries in 2000, the scholars at home and abroad had done a series of studies in health system performance from different points of view and countries,but very lillle in the performance of THCs.Utilization the public health organizations performance evaluation theory, from the perspective of the government, integrated the duty and function orientation of the primary health institutions, pursued the values of human oreientation and harmonious society,the study developed the concepts of performance of THCs is making full use of social resources to health service maximization and improves people’s health status obviously, under the development idea of“Health for all”and "six-in-one ", center on patients, guarantee the quality of health service. This concept is prospective,and reflects the essence and historical mission of THCs, and building up the performance evaluation theoretical framework form input, output,service quality,efficiency,cost-effectiveness and the development potential,et al.
2.Established the method of measure health service—"The standard service unit”
The service of THCs is very complicated and intercompared difficultly.Many researchers measure the quantity of health service based on time or cost,but not grasp the health service essence,such as technical content, labor intensity and risk degree. This study put forward:all the service items were transformed to the standard quantity of "The standard service unit”based on technical content, labor intensity and risk degree.So,we solved the technical and theory problem in measuring the quantity of health service by THCs.
3. Constructed the new composited indicators
On the methods of appraisal six dimensions,we broke through the qualitative methods and constructed the new composited indicators. "The comprehensive health index" reflects the entirety health state of population,“the quality of service " reflects the technical quality, non-technical quality and satisfaction of patients and so on.At length, We build up the mathematical model to calculated the true performance scores of THCs.
随着政府不断加大对农村卫生的投入,如何评价和监管乡镇卫生院的绩效,以促进其卫生服务质量、服务效率和成本效果不断提升成为亟待解决的难题,而绩效评价被认为是有效监督和管理医疗卫生机构的科学方法之一。本研究的目的是在综合分析国内外卫生机构和卫生系统绩效评价实践和理论的基础上,构建具有一定前瞻性的乡镇卫生院绩效评价理论框架,并在此基础上经过系列理论和实践研究,研制一套系统的乡镇卫生院绩效评价指标体系。为乡镇卫生院和各级卫生管理人员评价乡镇卫生院的绩效提供理论和实践经验,为政府监管农村卫生提供依据和政策建议。
研究方法
本研究运用卫生经济学、卫生统计学和社会医学的理论和方法,采用主客观相结合的方式,探索我国乡镇卫生院绩效评价的理论和方法。主要研究方法包括:1、构建绩效评价理论框架和绩效指标筛选方法包括:(1)文献荟萃法;(2)专家咨询法;(3)变异系数法;(4)假设检验法;(5)主客观交叉验证方法。2、指标权重的确定方法包括:(1)基于“功能驱动”原理的主观赋权法;(2)基于“差异驱动”原理的客观赋权法;(3)综合集成赋权法。3、绩效评价指标的信度和效度检验法:内评和外评交叉验证法,用Spearman等级相关检验两种方法评价结果的一致性,检验指标体系的效度,利用SPSS的信度检验模块,检验指标体系的信度。
研究结果
通过系统总结国内外卫生机构绩效评价方法和理论,紧扣我国卫生体制改革趋势和乡镇卫生院的功能定位,在多轮专家研讨和现场实证研究的基础上,取得以下研究结果:(1)对绩效理论进行深入分析并界定了乡镇卫生院的绩效。首先绩效有不同层次之分,乡镇卫生院绩效是指组织机构的绩效;其次绩效是多维的而非单维的,它是一个综合性的范畴;再次,绩效有价值取向,不仅体现在投入产出的效率,也体现以人为本和社会责任的价值;最后乡镇卫生院绩效应充分反映其“六位一体”功能和服务本质。在此基础上提出乡镇卫生院的绩效:在“人人享有基本卫生保健”和“六位一体功能”的发展理念下,以一定的质量保证、以“患者为中心”、利用各种社会资源获得卫生服务产出和有效改善居民健康程度的最大化。(2)绩效评价方法已进入绩效评价指标体系的创新时期,本研究借鉴和利用了这一时期较为成熟方法,将平衡记分卡的思想和关键绩效指标体系的思想进行融合,形成我国农村地区乡镇卫生院绩效评价指标体系构建的基本理论体系。在绩效评价实践方面,我国基层卫生机构绩效评价处在起步阶段,还缺乏一套科学系统的绩效评价方案。(3)构建六维度的乡镇卫生院绩效评价理论框架:服务效率、人均受益量、成本效果、服务质量、功能体现和发展潜力;(4)研制出一级指标6个、二级指标17个、三级指标78个的乡镇卫生院绩效评价指标体系,通过主观、客观和综合集成赋权法确定了指标的权重系数,其中一级指标的权重分别是:服务效率为0.20、人均受益量为0.15、成本效果为0.10、服务质量为0.25、功能体现为0.20,发展潜力为0.10。(5)构建“标准服务量”作为测算乡镇卫生院服务产出的单位,并把乡镇卫生院的各项服务按技术含量、劳动强度、服务风险三个因素折合成“标准服务量”的值,由此研究出测算乡镇卫生院服务产出的方法。同时确定乡镇卫生院投入成本包括四个方面:政府投入、机构自身投入、固定资产折旧和人力资源投入。由此可以测算乡镇卫生院的服务效率。(6)构建“居民健康指数”测算乡镇卫生院的服务效果。并确定法定传染病发病率、婴儿死亡率、高血压患者脑卒中发生率、EPI相关疾病发病率、高血压控制率和孕产妇死亡率作为测量辖区内居民健康水平的敏感指标,构建加权综合测量模型计算“居民健康指数”,由此可以计算乡镇卫生院的成本效果。构造其他“复合性指标”如机构投入、服务质量等并提出相应的测量方法;(7)对乡镇卫生院绩效评价指标体系效度和信度检验结果:内外交叉检验,对两组结果做Spearman等级相关统计分析,相关系数Rs=0.78(P<0.05),结果具有统计学意义,说明指标体系具有较好的效度。二级和三级指标体系克朗巴哈系数a标准值分别是:0.9012和0.8642,说明指标体系信度较好。(8)在指标体系研究的基础上制定乡镇卫生院绩效数据过录表,经信度和效度检验后,于2006年和2007年分别到青海和重庆做乡镇卫生院绩效评价。应用结果表明各地乡镇卫生院在服务效率、服务质量、人均收益量方面有明显的差异,普遍存在效率低下、服务质量差、农村居民对乡镇卫生院的服务利用不足等现象,部分乡镇卫生院没有很好履行“六位一体”的服务功能,以人为本的服务理念还需在过程服务中进一步加强。
研究结论
绩效评价是运用一定的评价方法、量化指标及评价标准,对组织为实现其职能所确定的绩效目标的实现程度,及为实现这一目标所安排预算的执行结果所进行的综合性评价。通过本项目系统研究,基本结论如下:
1、界定乡镇卫生院的绩效对乡镇卫生院而言,其绩效是在“人人享有基本卫生保健”和“六位一体功能”的发展理念下,以一定的质量保证、以“患者为中心”、利用各种社会资源获得卫生服务产出和有效改善居民健康程度的最大化。此概念反映了乡镇卫生院的服务本质和历史使命,具有一定的前瞻性。
2、乡镇卫生院的绩效评价理论框架乡镇卫生院绩效评价理论强调基层卫生机构的服务本质和社会功能。从投入、产出、质量、效率、效果和发展潜力等方面综合考虑,构建乡镇卫生院绩效评价理论框架。该理论框架丰富和发展了绩效评价理论体系。
3、研制乡镇卫生院绩效评价指标体系在乡镇卫生院绩效评价理论基础上,通过专家讨论和现场实证研究法,提出了一套乡镇卫生院绩效评价指标体系。研制的指标体系具有系统性、可行性和真实性。
4、基于“功能驱动”和“差异驱动”原理的主客观赋权法,并结合综合集成赋权法确定了指标的权重系数,赋权方法比较合理。
5、通过构建“标准服务量”、健康指数等复合指标,并提出相应的测量方法,为评价机构的效率和成本效果提供科学的测量方法,解决了绩效评价中技术难题。
6、通过内部和外部评价比较,多轮的现场实证研究,评价结果与卫生行政部门掌握的情况基本一致,同时指标体系重复度量效果较好,说明研制的乡镇卫生院绩效评价指标体系具有较好的效度和信度。
7、研究得出的乡镇卫生院绩效评价指标体系能从深层次、从量化角度比较不同乡镇卫生院绩效的优劣和绩效影响因素,对提高卫生行政部门的监管手段、促进乡镇卫生院又好又快发展具有重要的指导和实践意义。
研究创新
1、探索和完善了绩效和绩效评价理论
自世界卫生组织2000年发布191个成员国卫生系统绩效以来,国内外研究学者从不同角度、针对不同卫生体系做了进一步探索性研究,但对乡镇卫生院的绩效和绩效评价研究较少。本研究利用公共卫生机构绩效理论,立足政府外评的角度,结合基层卫生服务机构的职责和功能定位,追求以人为本和构建和谐社会的价值取向,提出乡镇卫生院的绩效是以一定的质量保证、以“患者为中心”、利用各种社会资源获得卫生服务产出和有效改善居民健康程度的最大化。乡镇卫生院绩效评价理论突出强调其服务本质和社会功能。从投入、产出、质量、效率、效果和发展潜力等方面综合考虑,构建乡镇卫生院绩效评价理论框架。
2、创建了卫生服务测量方法——标准服务量
镇卫生院的服务产出比较复杂,各种服务之间可比性差。国内外研究者对服务量的核算主要是以服务时间和服务成本为基本依据,但没有凸现卫生服务的本质,即技术含量、劳动强度和服务风险等因素。本研究在他人研究的基础上,提出从服务的技术含量、劳动强度和服务风险等因素综合衡量基层卫生机构的服务产出。首先界定“标准服务量”的内涵,利用专家法和现场实证法,确定其他各项服务的“标准服务量”的相对值。解决了镇卫生院服务量的测量理论和技术难题。
3、构建了新的复合性指标
在具体测算绩效各维度的方法上,突破过去以定性描述为主的方法局限,建立了新的综合性指标,利用“综合健康指数”测量居民健康效果,用于衡量某区域内居民总体健康水平的指标;“机构投入”反映了一定时期内机构消耗的社会资源;“服务质量”反映了机构的技术质量、非技术质量和居民满意度等;实现了镇卫生院成本投入“货币化”的测算办法等。最后通过数学模型测算出乡镇卫生院绩效具体得分。
Objectives
With the more and more health resources being put into the rural area from the government continuously,it is the problem needed to be solved that how to improve and increase the health service quality,efficiency and cost - effectiveness of THCs. As a scientific method, performance assessment has been widely and effectively used to supervise and administrate health service organizations.
This study was aimed to use a serise of theoretic analysis and practical research to build up the performance evaluation theoretical framework and indicators system of THCs based on reviewing the literatures at home and abroad. Then provide some evidence for the government to implement the performance assessing, and also help the health administrators and researchers correctly evaluate the performance and quality of THCs so as to develop reasonable strategies suggestions in improving THCs performance.
Methods
In this study,lots of theories and methods were used from health economics,health statistics,social medical and health manangement,and based on objective and subjective assessment methods to explore the theory and methods of performance evaluation of THC in rural area. Main methods such as: 1.the research methods of performance evaluation theoretical framework and indictors were: (1) Literature searching ;(2)Experts discussion and Delphi method;(3) Variation coefficient method;(4) Hypothesis test;(5) The cross verification of objective and subjective assessment method.2. The method of computing the indicators weight including: (1) Subjective principle of the function’s drive; (2)Objective principle of the difference’s drive;(3)The comprehensive principle on the weight coefficient. 3.The methods of reliability and validity test of indictors system are Spearman rank correlation test method and Cronbach’s alpha coefficient test way.
Results
By systematical summing-up and comparing the performance evaluation methods and theories of domestic and overseas,focusing on rural health system reform trend and THC’s functional orientation,and through experts discussion and empirical research,the results of this study are as follows: (1)Some relevant performance theory analyzed deeply and put forward the conceptation of THC performance.Firstly, performance is described in different levels by systems,organizations and individual,and THC performance belongs to organizations;Secondly,performance is multiple dimensions,bu not a single one,it’s a comprehensive concept;Thirdly,it has Value Orientation,not only embodies the input-output efficiency, but the value of“Human-Oriented”and social responsibilities;Finally,THC performance should reflcet fully the function of“six-in- one”and service responsibility. On these theoretical analysis, the concepts of performance of THC is making full use of social resources to health service maximization and improves people’s health status obviously, under the development idea of“Health for all”and "six-in-one ", center on patients, guarantee the quality of health service. This concept is prospective,and reflects the essence and historical mission of THCs in our country. (2) The of methods performance evaluation have developed to the innovation term of indicators system,and then absorbs and utilizes these mature methods, integrates the balanced scorecard(BSC)and Key performance indicators(KPI). In the end, we formed the theoretical system of THC performance evaluation in rural area.In the performance evaluation practice, the research and utilization of performance appraisal is still in its Starting period in primary health organizations,there is no scientific and systematic program of performance evaluation for THCs.(3)Having constructed the dimensions of performance assessment which contains six aspects,such as service efficiency, the quantity per person enjoys, the cost-effectiveness, the realization of function, the quality of service and the development potential in the THCs.(4)Building up THC performance evaluation indicators system,which composes of 6 first class indictors, 17 second class and 78 third class indictors.The weight coefficients of the three-level indicators were calculated by subjective principle of the function’s drive,objective principle of the difference’s drive and the comprehensive principle.The weight of 6 indicators of the first class are 0.20,0.15,0..10,0.25,0.20,0.10.(5) "The standard service unit”was chosen as the smallest unit to measure the quantity of health service provided by THCs.Then, all the service items were transformed to the standard quantity of "the standard service unit”based on technical content, labor intensity and risk degree. On the other hand,the input of THC includes: government input, self-investment, depreciation of fixed assets and capital and human resource.Then we explored the method of measure the economic efficiency of THCs.(6) Creating the new comprehensive indicators—"The comprehensive health index" reflects the entirety health state of population,the indicators of the incidence of legal infections, the infant mortality rate, stroke incidence of patients with hypertension,the incidengces of EPI related diseases,the control rate of patients with hypertension and maternal mortality were selected to measure the health status for residents.and other complex indicaors as“the quality of service " reflects the technical quality, non-technical quality and satisfaction of patients and so on. (7)The reliability and validity of indictors system: Spearman ranking correlation coefficient is 0.78(P<0.05),and Cronbach’s alpha are 0.9012 and 0.8642 of the second class indictors and the third class indictors,it was showed that the reliability and validity of the indicators system is very good. (8)We made the questionnaires of THCs performance on the based of the indicators system.By the reliability and validity tested, had done the fields survey appraisal of THCs in 2006 an 2007 in Qinghai Province and Chongqing.The results showed there had obvious difference in service efficiency, cost-effectiveness,and service quality in THCs in different area, and low efficiency,low service quality and insufficient utilization of health services in rural areas are very common. Some THCs can not fulfill the function of“six-in-one”, the service idea of“human-oriented”must be strengthened in work.
Conclusions
Based on the results of the research,the conclusions and recommendations could be put forward.(1) The concepts of performance of THC is making full use of social resources to health service maximization and improves people’s health status obviously, under the development idea of“Health for all”and "six-in-one ", center on patients, guarantee the quality of health service. This concept is prospective,and reflects the essence and historical mission of THCs in our country. (2)Based on the service functions and social functions of THCs,the theorical framewark of perforamce evaluation of THC has six dimensions: service efficiency, the quantity per person enjoys, the cost-effectiveness, the realization of function, the quality of service and the development potential.This theorical framewark enrichs and develops the perforamce evaluation theorical system.(3) The performance evaluation indicators system is set up surrounding firmly the performance evaluation theory and function positioning of THC.The whole indicators system is valid,feasible and realible.(4)The weight coefficient of the three-level indicators is based on subjective principle of the function’s drive, objective principle of the difference’s drive and the comprehensive principle on the weight coefficient.These methods were reasonable.(5) By composing "the standard service unit”and“The comprehensive health index”,then forming the revelant measurement methods,it solved the technical problems about appraisal methods of efficiency and cost-effective.(6) Through compared evaluation, more times verified in fields and Cronbach’s alpha coefficient tested,the result demonstrates that the performance indicator system is steady, practicable and has good reliability and validity.(7) From the perspective of the government, this performance evaluating indicators system could systematically disclose that in what level the Township Health Centers, could provide some good advice for the government to implement the performance assessing, and also help the health administrators and researchers correctly evaluate the performance and quality of the organizations so as to develop reasonable strategies suggestions in improving the THC’s performance.
Innovation
1.Explored and improved the performance and performance evaluation theories
From WHO promulgating the health system performance of 191 member countries in 2000, the scholars at home and abroad had done a series of studies in health system performance from different points of view and countries,but very lillle in the performance of THCs.Utilization the public health organizations performance evaluation theory, from the perspective of the government, integrated the duty and function orientation of the primary health institutions, pursued the values of human oreientation and harmonious society,the study developed the concepts of performance of THCs is making full use of social resources to health service maximization and improves people’s health status obviously, under the development idea of“Health for all”and "six-in-one ", center on patients, guarantee the quality of health service. This concept is prospective,and reflects the essence and historical mission of THCs, and building up the performance evaluation theoretical framework form input, output,service quality,efficiency,cost-effectiveness and the development potential,et al.
2.Established the method of measure health service—"The standard service unit”
The service of THCs is very complicated and intercompared difficultly.Many researchers measure the quantity of health service based on time or cost,but not grasp the health service essence,such as technical content, labor intensity and risk degree. This study put forward:all the service items were transformed to the standard quantity of "The standard service unit”based on technical content, labor intensity and risk degree.So,we solved the technical and theory problem in measuring the quantity of health service by THCs.
3. Constructed the new composited indicators
On the methods of appraisal six dimensions,we broke through the qualitative methods and constructed the new composited indicators. "The comprehensive health index" reflects the entirety health state of population,“the quality of service " reflects the technical quality, non-technical quality and satisfaction of patients and so on.At length, We build up the mathematical model to calculated the true performance scores of THCs.
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