管理式醫療用來控制醫療品質的方法介紹

The Methods of Quality Assurance under Managed Care

健保開辦以來，民眾就醫可近性提高，伴隨而來的是民眾對醫療品質的要求也比以往增加。雖然各大醫院開始把提升醫療品質當成年度工作之重點項目，但至目前為止，台灣未有一套廣被大眾所接受的醫療品質確保方法。本文希望藉由介紹美國管理式醫療中確保醫療品質的方法，思考可能適合台灣健康照護體系的醫療品質確保方式。美國健康照護體系開始重視醫療品質的衡量及改善，是最近15年的事，尤其是管理式醫療機構為爭取納保人，對醫療品質的提升更是不遺餘力。在醫療品質確保方面，管理式醫療除了使用傳統上由Donabedian所發展出的結構、過程、及結果三構面之品質測量工具外，管理式醫療機構也使用同儕審核、醫療步驟適當性之評估、醫療服務提供者檔案、及報告卡等方法以確保醫療品質。其中尤其是報告卡，更已廣泛的被美國健康照護體系所採用作為提升醫療品質的重要工具。建議衛生主管當局能在每一縣市設置一個類似美國同儕審核機構的中立單位，使用管理式依療中的回溯性、同步性、及前瞻性三方面的審核以確實做好醫療品質的把關工作。並且建議衛生主管當局能發展醫療品質報告卡，尤其是醫院品質報告卡，一方面能作為民眾選擇醫院的依據，另一方面也能將醫院提升醫療品質的成果公諸於社會大眾。

After the National Health Insurance began, the increasing accessibility to medical care has been accompanied with the demand for high quality of medical care. Hospitals have regarded quality improvement as one of the most important tasks in response to the demand from people. However, there is no well-accepted quality assurance means available in Taiwan up to date. The purpose of this paper is to help health policy makers apply the possible tools to assure quality of medical care through the introduction of the methods of quality assurance used by managed care in U.S.. U.S. Health delivery system has been focusing on the measurements and improvements of quality of medical care since fifteen years ago. Particularly, managed care organizations (MCOs) have spent lots of energy and money on the quality improvement in order to increase the number of enrollees. For example, MCOs have developed report cared and provider profiles to assure quality of medical care. MCOs does not only use the traditional quality measurements consisting of structure, process, and outcome developed by Avedas Donabedian, but they also utilize peer review, appropriateness evaluation, provider profiling, and report care to assure quality. Among the tools for quality measurement and assurance, report card has become the most widespread used in U.S.. It is recommended that the Department of Health can establish organizations like peer review organizations (PROs) in U.S. in every county to monitor quality of medical care. The organizations can apply the retrospective, concurrent, and prospective measurements developed by managed care to monitor quality. It is also recommended that the Department of Health can develop report card, especially hospital report card. The report card can help people select the right hospital, and it also can help hospitals publish the outcome of implementation of quality improvement program.