應用離散事件電腦模擬技術推估主治醫師工時限制對我國醫療服務提供之影響——以六個外科系專科別為例

Application of discrete-event simulation modeling to project the effect of limiting the work hours of visiting staff on medical service volume: the case of 6 surgical specialties

目標：主治醫師納入勞動基準法的議題爭議許久，然而有關制定工時上限對醫療服務提供與民眾就醫衝擊的相關研究尚付之闕如。本研究以電腦模擬方法推估健保特約西醫醫院六個外科系科別之主治醫師工時限縮後對醫療服務量的影響。方法：以問卷調查與深度訪談收集醫師工作內容、每項工時及排班邏輯；分析健保申報資料之全年門診、檢查及手術服務、手術耗用時間等醫療服務量資料，建構主治醫師全年醫療服務量現況模型，並依據三種可能工時限縮方案（每週總工時及連續工時上限：80/28, 76/28, 72/24）進行推估，比較其對於醫療服務提供的影響。結果：相較於主治醫師現行工作現況，三種工時限縮方案皆可能導致門診量的減少與手術排程的延後，且對於區域醫院層級以下的醫療服務提供者影響較大。工時限縮方案中以每週工時上限72小時，連續工時上限24小時的方案，對醫療服務提供與民眾就醫權益影響最鉅。結論：本醫師工時模型及分析結果可供主管機關做為制訂主治醫師工時限縮決策之參考。

Objectives: Research is lacking on the effect of implementing work-hour limitations for hospitals' visiting staff in terms of the provision of medical services and accessibility to the public. This study used discrete-event computer simulation to estimate the effect of limiting the work hours of visiting staff on the medical service volume of 6 surgical specialties in hospitals under the National Health Insurance system. Methods: In-depth interviews and questionnaires were used to collect data on visiting staff's work content, elapsed working time, and scheduling logic. We also analyzed the National Health Insurance claims database to obtain the annual volume of outpatients, examinations, and surgical services and the total elapsed time. Based on these data, we developed a medical service model for the 6 surgical specialties and proposed 3 work-hour limitation models (maximum weekly working hours/maximum hours of continuous work: 80/28, 76/28, and 72/24); the effects of the models on the provision of medical services were compared. Results: Compared with the model currently applied for visiting staff, the model in which work hours were reduced led to decreased outpatient volume and delay in the surgical schedule. It had a greater effect on hospitals with an accreditation level lower than that of regional hospitals. The work-hour limitation model with a maximum of 72 working hours per week and a 24-hour limit on continuous duty had the greatest effect on the provision of medical services. Conclusions: The model and research results established in this study provide the competent authorities with a reference when making decisions regarding the limitation of work hours for visiting staff.