摘要
随着社会经济的快速发展，居民对卫生的需求更加多样化，对我国的卫生服务体系提出更高要求。为更好满足居民的卫生需求，实现人人享有卫生保健的目标，国家提出要积极发展社区卫生服务，逐步形成功能合理、方便群众的卫生服务网络。近些年来，社区卫生事业不断发展，已逐渐被居民认可，并承担提供基层公共卫生和医疗卫生服务的职能。社区护理作为社区卫生服务的重要组成部分，是实现人人享有初级卫生保健目标的基础环节。社区护士充分利用社区资源，为个人、家庭和人群提供卫生服务，特别是在初级保健中发挥了重要的作用。
本研究旨在以系统理论、激励理论和行为科学理论为基础，在文献分析的基础上，采用科学的方法广泛征询相关专家意见，建立适合我国国情的城市社区护理绩效评价体系。根据社区护理绩效评价指标体系的特点和评价的目的选取适合的数据包络分析模型进行研究。选取一定范围的社区卫生服务中心，依据已建立的指标体系，进行数据的收集和分析整理，带入相关模型进行绩效评价。分析影响城市社区护理绩效的影响因素，并应用质性研究的方法进一步揭示社区护理管理中存在的问题。通过对实证研究结果的分析，提出适合提升我国城市社区护理绩效的对策。
本研究采用文献回顾法和Delphi法构建适合我国国情的城市社区绩效评价体系。应用数据包络分析法（data envelopment analysis，DEA）的CCR模型和BBC模型对吉林省9市（州）的城市社区卫生服务中心的社区护理技术效率、纯技术效率和规模效率进行评价，采用描述性分析、多元线性回归分析、Kruskal-Wallis检验、Jonckheere-Terpstra检验和Mann-Whitney U检验进行分析。采用质性研究的方法，进一步揭示社区护理管理中存在的问题。
通过研究，建立以投入和产出为衡量社区护理绩效的指标体系。投入包括人力、物力、财力和管理4个维度，社区护士数量、社区护士培训、社区卫生服务支出、社区护士相关支出、社区卫生服务中心环境条件、社区卫生政策和社区卫生信息管理7个条目，每千人口护士数量、社区护士培训比例、公共卫生和药品支出、政府财政补助、社区护士平均工资及绩效补助、社区护士培训支出、中心业务用房面积、配套社区卫生政策落实和卫生信息技术的应用情况9个指标；产出包括公共卫生服务、医疗卫生服务和满意度3个维度，健康档案、健康教育、妇幼保健、精神病管理、计划免疫、老年保健、慢性病患者健康管理、传染病管理、门诊护理服务、双向转诊和居民对护理工作满意度10个条目，健康档案建档率、健康教育人次数、新生儿访视率、0～6岁儿童管理人数、孕产妇管理人数、精神病管理人数、预防接种建证率、老年人健康管理率、高血压患者健康管理率、糖尿病患者健康管理率、传染病管理人数、（全科）门诊人次数、转入转出人次数和居民对护理工作满意度调查14个指标。
通过对2010年～2012年吉林省城市社区卫生服务中心社区护理绩效的分析显示，城市社区卫生服务中心护理投入资源逐年增加，到2012年，吉林省城市社区每千人口社区护士数量为（0.239±0.195）人，社区护士培训比例为71.5%，政府财政补助为（379.934±571.591）万元，而公共卫生和药品支出已达（454.538±806.177）万元。吉林省城市社区护理的各项指标差异性依然较大，特别是公共卫生和药品支出、政府财政补助、管理支出、健康教育人次数、传染病患者管理人数、转入转出人次数和满意度的变异系数均大于1.5，离散程度明显高于其他指标。然而社区护士培训比例、社区护士平均工资及绩效补助、健康档案建档率和预防接种建证率的变异系数均小于0.5，提示各社区间差异性较小。
以CCR模型计算出115个社区卫生服务中心社区护理绩效的技术效率平均值为0.759±0.312。技术效率值为1的有61个（53.0%），技术效率小于1的有54个（47.0%）。基于BCC模型在规模报酬可变的前提下，计算出115社区卫生服务中心社区护理绩效的纯技术效率为0.767±0.314，其中DEA有效的有73个（63.5%），共有42个DMUs纯技术效率小于1，占全部的36.5%。2012年规模效率为0.990±0.494，规模有效的DMUs共有100个。经过2010年、2011年和2012年逐年对比和分析，吉林省城市社区护理绩效正在不断提升，技术效率呈上升趋势，规模效率较为稳定，纯技术效率提高明显，提示随着国家政策的引领，吉林省城市社区护理绩效水平不断提高，随着规模的不断扩大，技术效率也得到提升。
通过对技术效率、纯技术效率和规模效率的统计显示，投入资源中管理支出是技术效率和纯技术效率的主要影响因素，可通过控制管理支出提高技术效率；社区护士平均工资及绩效补助是规模效率的主要影响因素，可通过提高社区护士待遇提高规模效率；在产出服务中，孕产妇管理人数和高血压患者健康管理人数对技术效率和纯技术效率有较大影响，可通过提高这两方面的服务增强绩效。
通过质性研究发现，社区护理操作（护理活动）具有多样化的特点，缺乏统一的量化标准，科学合理计算护理工作量有一定困难。社区护士能力差异较大，对不同级别的护士用统一标准进行评定缺乏公平性。社区卫生服务机构为公益性单位，支配的经费有限，实施绩效考核的奖励机制不完善。社会对社区卫生服务的认同性虽然不断增强，但是一些居民不配合社区卫生人员的工作，导致一些社区卫生工作开展受限。社区护理人员不足，很多社区卫生工作难以完成。
基于以上结果，提出如下对策。在人力方面，增加社区护士比例，保证人力资源，满足居民需求。严格制定社区护理人员准入制度，提高社区护士能力水平，不断完善社区护理服务。建立我国社区护士核心能力标准，进行科学的社区护理绩效管理，提高人员和组织效能，实现组织高效运转。在财力方面，充分利用政府财政支持，制定财务审核制度，规范经费使用。对财政补助按社区规模、基础建设情况进行分配，并对剩余的经费进行再分配，以保证资金的优化配置。提高社区护理人员的工资，确保其待遇不低于所在地区城市职工平均收入水平。在物力方面，规范社区卫生服务机构建设，提高社区建筑标准，同时依据社区特点，配备适宜的设备。
综上所述，要提高社区护理绩效，应从人力、物力和财力等多方面入手，建立各种社区护理服务规范，不断提升社区护理绩效水平，为居民提供切实可行、行之有效的基层护理服务。
With the development of social and economic rapidly, the residents' health needsbecome more diversified. There’re higher demands on our health service system. Inorder to meet the health needs of the residents better and to achieve the goal of Healthfor All, the CPC Central Committee, the State Council issued the Decision on HealthReform and Development in1997. It is proposed to develop community healthservices, and a health service network will be founded with rational function. Inrecent years, community health which is developed quickly, has been graduallyrecognized by the residents, provided basic public health and medical health servicesfor people. Community health nursing is an important part of community healthservices. It will be the basic link for achieve universal primary health care in China.The community health nurses make full use of community health resources forindividuals, families and populations to provide health services, especially in primarycare.
This study was designed on the basis of system theory, incentive theory andbehavioral science theory. After the analysis of the literature and the advice fromextensive experts, the evaluation system of urban community performance has beenestablished. According to the characteristics of community health nursingperformance evaluation system indicators and evaluation purposes, appropriate dataenvelopment analysis model is selected for further study. A range of communityhealth service centers will be evaluated by the established index system. Then, put thedata into the model for performance evaluation. Analysis the impact factors whichaffected the performance of the urban community health nursing, and the applicationof qualitative research methods for further study on the existing problems ofcommunity health nursing management. After the analysis of the empirical results,countermeasures to enhance our urban community health nursing performance theproposed.
With the rapid social and economic development, the residents' health needs more diversified, higher demands on our health service system. In order to better meetthe health needs of the residents, the goal of health for all, the countries shouldactively develop community health services, and gradually form a rational function,and health service network to facilitate the masses. In recent years, the cause ofcommunity health development, has been gradually recognized by the residents, andassumed the functions of the grass-roots public health and health services provided.Community nursing as an important part of community health services to achieveuniversal access to primary health care goals a basic link. The community nursesmake full use of community resources for individuals, families and groups to providehealth services, especially in primary care has played an important role.
This study was designed on the base of system theory, incentive theory andbehavioral science theory. Scientific methods are used to get the advice fromextensive experts to establish urban community performance evaluation systemsuitable for China.
According to the characteristics of the community nursing performanceevaluation system indicators and the evaluation purposes, appropriate dataenvelopment analysis models were selected for study. A range of community healthservice centers were selected for performance evaluation by the system. Collecteddata were put into the DEA model for analyzing. Impact factors affecting theperformance of the urban community nursing would be found. Meanwhile, theexisting problems would be revealed by the application of qualitative researchmethods. The countermeasures would be proposed for enhancing our urbancommunity nursing performance.
According to the literature review and the Delphi method, urban communityperformance evaluation system is established. The research object is communitynursing of urban community health service centers in9cities of Jilin Province.Technical efficiency, pure technical efficiency and scale efficiency are evaluated byCCR model and the BBC model of DEA. Descriptive analysis, multiple linearregression analysis, Kruskal-Wallis test, Jonckheere-Terpstra test and Mann-WhitneyU test are used for study. Qualitative research method is used to uncover the problemsfor the community nursing management.
After research, indicators for community nursing performance measurementsystem is established and divided into inputs and outputs. Inputs include the four dimensions of the human resources, material resources, financial resources andmanagement. The seven items of the inputs are the number of community nurses,community nurses training, the expenditure of community health service, relatedexpenses of community nurses, the environmental conditions of the community healthservice centers, community health policy and community health informationmanagement. The9indicators are the number of nurses per thousand population, theproportion of community nurses training, the expenditure for public health andpharmaceutical, government financial assistance, the average wage and performanceallowance of community nurses, training expenditures for community nurses,business space, the implementation of the supporting community health policy andhealth information technology application. The outputs include3dimensions ofpublic health services, medical services and satisfaction. The10items of outputs arehealth records, health education, maternal and child health, mental illnessmanagement, planning immunization, elderly care, health management for patientswith chronic diseases, infectious disease management, general outpatient, two-wayreferral and residents’ satisfaction for nursing job. The14indicators are health recordscreating rate, the number of health education, newborn visiting rate, the number ofchildren management which aged0to6, number of maternal management, thenumber of psychiatric management, the rate of vaccination, the rate of elderly healthmanagement, health management of patients with hypertension, health managementof patients with diabetes, the number of the management patients with infectiousdiseases, the number of outpatient (general), the number of transferring consultation,and residents satisfaction for nursing work.
According to the results from2010to2012, the investment increased year byyear for urban community health nursing in Jilin Province. By2012, in urbancommunities Jilin Province, the number of community nurses per thousand populationis0.239±0.195, community nurses training rate is71.5±35.2%, governmentfinancial assistance is379.934±571.591million RMB, expenditures for public healthand pharmaceutical reached454.538±8,061,770RMB. The difference of urbancommunity nursing indicators is still various, especially in expenditure for publichealth and pharmaceutical, government financial assistance, management expenses,the number of health education, the number of infectious diseases patientsmanagement, the number of transferring consultation and satisfaction whose coefficient of variation is more than1.5, and the dispersion degree is significantlyhigher than other indicators. Also found that the coefficient of variation is less than0.5in the proportion of community nurses training, community nurses average wageand performance allowance, health records creating rate and the preventivevaccination rate.
According to the comparison and analysis from2010to2012, communitynursing performance is rising in urban cities of Jilin Province. With the guidance ofnational policy, urban community nursing performance of Jilin Province continueimproving.
After multiple regression analysis of technical efficiency, pure technicalefficiency and scale efficiency, in input resources, the management expenses is themain factors for technical efficiency and pure technical efficiency; while communitynurses average wage and performance allowance is the main factor for the scaleefficiency. In output services, the number of maternal health management persons andthe number of hypertensive management patients have a greater impact on technicalefficiency and pure technical efficiency; while preventive vaccination rate and healthrecords creating rate have a greater impact on the scale efficiency.
During qualitative research, it is found that the lack of community nursingservices criteria made difficulties for the rational calculation of nursing workload. Forthe various community nurses abilities, it is seemed to unfair that different levels ofnurses were evaluated by the same standards. Performance appraisal mechanisms isinadequate. Although social recognition of community health services continue to beenhance, some residents wouldn’t like to work together with community healthworkers which coursed limited development of community health service. Lack ofcommunity health nurses is one of the reason for difficulty completement incommunity health nursing.
Based on the findings, suggestions are proposed. For human resources, theproportion of community nurses should be increased to ensure the human resourcesmeeting the residents’ needs. Strict access system should be set up to improve thecommunity nurses ability and community nursing services. The establishment of CoreCompetency Standards for community nurses will improve community nursingperformance management and organizational effectiveness. For financial resources,more measurement should be taken in making full use of government financial support, the development of the financial audit system and standardizing the use offunds.
In the end, to improve the performance of community nursing, various factorsshould be considered. With the establishment of a wide range of community nursingservices specification and improve the community nursing performance constantly,effective commuty health services would be deliveried for all the residents.
引文
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