北部某區域醫院醫務行政室持續變革與學習實務經驗分享

Practical Experiences of Constant Transformation and Learning: A Case Study of the Medical Administrative Office at a Regional Hospital in Northern Taiwan

醫務行政室（簡稱醫行室）係為本院一級行政單位，依業務範疇分為四組，為提升本室服務價值，在醫院「策略經營暨提升績效團隊會議」以功能部門方式呈現，經由平衡計分卡品質管理工具改善本室各項醫療服務措施，致力改善各項作業流程，制定多件作業程序書及工作指導書並進行內部稽核，使作業現場人員與標準作業流程達成說寫做一致，藉由參與各項競賽做為自我監測之依據，同時竭盡所能提升服務品質，增加內外部顧客滿意度，降低顧客抱怨，不斷進行各項流程與服務之持續變革與學習。本室經由持續不斷之變革與學習，在內外部顧客滿意度逐年提升；顧客抱怨件數逐年降低；門診醫令及出院病摘完成後24小時內電子簽章完成率逐月增加；建置電子簽章之病歷表單逐年增加；參與內外部各單位舉辦的品質提升活動競賽屢獲肯定屢次得獎。品質的提升要經由持續不斷進行改善與學習，在監控與評核過程中發現之異常事項，應隨即以PDCA及SDCA模式進行改善，建立一個兼具維持與改善之管理系統，才能達到永續經營的目標。

The Medical Administrative Office (hereinafter referred to as “the Office”) is one of the first-tier administrative units of the hospital, and it has four subdivisions supervising different businesses. In order to enhance the service value of the Office, these subdivisions act as four functional departments at the hospital’s “strategy performance management and improvement team meeting.” The Balance Scorecard (BSC) is used as a strategy performance management tool to improve the quality of medical services in all subdivisions of the Office. We are committed to improve all operating procedures by developing many operating procedure handbooks and tutorials, and conducting internal audits to ensure that the performance of on-site staff is in accordance with the standard operating procedures. We’ve also used various competitions as the basis for self-monitoring. By constant transformation and learning of all operating procedures and services, we strive to improve the service quality, increase customer satisfaction (both inpatient and outpatient), and reduce customer grievances. Through the Office’s constant transformation and learning, the satisfaction rates of both inpatient and outpatient have been increasing yearly, the number of customer grievances decreasing yearly, the electronic signature completion rates within 24 hours after outpatients receiving physician orders and inpatients receiving discharge requests increasing monthly, and the number of medical records written in electronic signature increasing yearly. Besides, the Office has entered various quality improvement contests both inside and outside the hospital and has repeatedly won and been recognized. Quality improvement requires constant transformation and learning. Any aberration found during the monitoring and evaluating processes should be dealt with and fixed using PDCA and SDCA models. A managerial system that possesses both sustainability and improvement capability can achieve the goal of sustainable development.