實施臨床路徑對醫療資源耗用及照護品質之影響──平衡計分卡觀點

The Impact of the Clinical Pathways on Resource Consumption and the Quality of Medical Care–From the Perspective of Balanced Scorecard

面對醫療資源受限且競爭日益激烈的環境，如何兼顧醫療資源耗用及照護品質是全世界醫療管理皆重視的議題。本研究提出一整合平衡計分卡於臨床路徑實施的觀念性架構，以協助釐清實施臨床路徑的價值創造過程與不同構面績效指標間之連結及互動全貌；並依據此邏輯架構呈現個案醫院的醫療團隊如何導入臨床路徑的整合配套作法，可作為指引實務運作的具體參考模板。運用平衡計分卡可更有效地協助跨部門醫療團隊規劃與溝通協調，來達成醫院所賦予的策略目標；同時此觀念性架構與實施臨床路徑的整合配套作法，亦有助於解釋現有文獻有關實施臨床路徑對於醫療資源耗用及照護品質影響存在不一致研究結論之可能原因。經以個案醫院先導實施的「腹腔鏡膽囊切除術」、「肛門及廔孔手術」、「疝氣手術」等三項臨床路徑，共計1,211件患者案例為研究樣本，採t檢定及卡方檢定進行假說驗證。整體而言，個案醫院從醫療照護團隊學習成長面的投入、標準模式的流程建立等配套措施採行後，不僅能維持照護品質，也同步達成減少住院日、改善收益差等效益。

It is of paramount importance that healthcare managers to reconcile cost-quality conflict to establish or maintain competitive advantages when facing head-to-head contest and an increase in resource constraints. In this study, we constructed a conceptual framework based on the balanced scorecard to clarify the value creation process in the implementation of clinical pathways, and the links and interactions between key performance indicators in different dimensions of the balanced scorecard. Essential steps to a successful implementation of clinical pathways in a hospital were also identified, with a hope that this framework can be used as a reference template in other hospitals. The application of this balanced scorecard framework can effectively coordinate the medical team from different departments to achieve the assigned strategic goal. Moreover, inconsistencies in the results of previous studies about the impact of the clinical pathways on resource consumption and the qualities of medical care could be reconciled by this framework. We analyzed 1,211 cases classified as the following three different clinical pathways using Student’s t and Kappa test: laparoscopic cholecystectomy (LC), anus and fistula surgery (AF) and hernia surgery (H). The results support our hypotheses. In general, after personnel training and the establishment of new standards for the clinical pathways, the average length of stay decreased, the profitability improved, and the quality of medical care was maintained.