資訊模組協助醫院評鑑成績單之製作與分析

A Computer Module with Performance Sheets for Hospitals to Indicate Needed Improvements after an Accreditation Assessment

雖然已公佈了醫院評鑑基準版本的評量項目，評鑑通過與不過的成績公佈，不能滿足醫院對檢討改善上的需要。如果醫院想要改善進步而非停滯不前，就需另賴以更多的訊息。本研究以醫院評鑑經營管理篇的67項（其中10項為符合與不符合的2點計分，57項為另評定有優良的3點計分），模擬資料（1）分析評鑑的章節分數的可加性，（2）利用常模參照計算契合度及偏離指標，（3）利用微軟Excel建立資訊模組製作受評醫院的成績表及揭露可以改善的評量項目。利用偏離指標及受試者間的契合度，繪製散佈圖，結果顯示，研究資料呈單向度的分數可加性，資訊模組的成績表製作，可以回饋給醫院更多可資改善及檢討的訊息，期以客觀地回饋給醫院作為改善及檢討的參考。

Although new criteria for hospital accreditation have been announced in Taiwan, a simple pass-or-fail report card does not tell hospital administrators what needs improvement. Such information is required if hospitals are expected to improve rather than stagnate. Therefore, we used an accreditation inventory with 67 management items, 10 of which were scaled with 2 categories and 57 with 3 categories. We investigated (1) whether the study scores are addible, (2) how to calculate both indictors of coherence and deviation using the norm-criterion-based method, and (3) whether it is possible to generate a Microsoft Excel performance sheet that shows what items need to be improved. Both a deviation index and a coherence coefficient were used to draw both scatter plots and bar-chart plots. We found that the study data could be unidimensional and thus allow scores to be addible. The computer program created to analyze the accreditation inventory can be used to provide feedback for improvements. This should help administrators efficiently and objectively evaluate their hospital's performance strengths and weaknesses and focus on areas that need improvement.