臺灣博碩士論文加值系統

隨著健保體制逐漸朝向總額控制與前瞻式付費，對於醫師主管的需求量也隨之增加。醫師主管必須在醫療系統中扮演著監督執行者與臨床工作者的雙重角色，但由於傳統的醫學教育與管理教育有著大相逕庭的模式，對於一位醫師在原本的臨床工作再加上管理事務之後可能產生的角色衝突，不禁要讓我們開始思索醫師主管如何融合管理者與醫療工作者的雙重角色，以及醫師主管在決策管理及執行上會有何種行為模式。
當醫師在職業生涯中進入管理階層，該如何在未經過專業管理教育的背景下參與醫院經營，並且如何妥善運用資訊管理系統，在會計管理上迅速掌控醫院的盈餘。本研究一方面就台灣目前醫療管理的生態加以探討，另一方也就醫師主管對於管理工具的運用加以研究。
本研究藉由探討總額預算制度下三個影響醫師主管成本意識的因素包括：醫師主管職權、財務預算系統設計特徵、決策管理與決策控制之影響行為，期望去瞭解醫師主管的職權運用對成本意識之影響，更深入探討財務預算系統的運用，如何達成決策管理。研究方法則是運用問卷調查去分析各大醫院內醫師主管的行為，運用量化的結果作分析。問卷內容分為科室主管正式及非正式職權、財務資訊系統設計準則、財務資訊系統的使用對成本觀念之影響。透過醫界資深主管的轉介，進行便利抽樣。為配合臺灣本土醫療產業多元化特性，樣本來源維持多樣化，挑選不同評鑑層級與權屬別醫院內之醫師主管進行施測。問卷填寫過程直接由受訪者回答，問卷內容設計參考已發表論文之量表，並針對本土化考量作修改並進行前測。
本研究實證結果顯示，在醫師主管的管理經驗與他們專業目標和價值角色間的衝突下，總額預算下的財務預算系統界定財務責任，能降低管理角色模糊。然而，財務預算的決策控制角色卻沒出現相似效應。醫師主管的正式職權會影響財務預算系統的控制目的，但並沒影響醫師成本意識，許多現象指出醫師主管不注意財務預算的控制角色，因為財務預算這些資訊無法完全反映出他們績效或臨床單位的產能，因此，它將不會對成本意識有影響。
我們希望過研究的結果讓身兼照護病人與管理職責的醫師主管可以預期到在管理與專業領域中可能遇到問題以及如何克服處遇的與處理的方式，進而成為健康照護體制下一個有效的領導者，並提供日後可能晉升管理階層的醫師一個管理行為模式的參考。同時本研究也希望釐清不同醫院背景下的醫師主管，在擔任雙重角色時所出現相似與不同的管理模式。最後更希望這樣的研究發現可以提供醫師主管架構出新的管理模式訊。如何透過一個客觀的資訊來源表現出慣用正式或非正式職權的管理行為，位在不同層級的醫師主管，具備怎樣的職權使用特性。這將影響著未來醫療管理教育、醫院管理模式、以及醫院管理生態。

With the tremendous changes of health care system in Taiwan, more physicians participate in the management of the hospitals. Physicians are a key stakeholder in hospitals and their involvement in resource management is seen to be critical to hospital survival. However, the roles of being a health care provider and manager conflict each other. In addition, for physician managers who received only medical but not formal managerial education, their behavior determining decision control and decision management necessitate further evaluation. The purpose of this study is designed to enable an assessment of the relative impact of formal authority that stems from the delegation of decision rights and the informal authority that stems from individual power and influence. The model examined also enables us to assess the consequences of these two forms of authority on organizational outcomes and the influence of key performance index (KPI) on this relation.

Questionnaire data were collected from physician managers in large hospitals in Taiwan. The purpose of the questionnaire was to assess formal and informal authorities, the antecedent conditions influencing the use of KPI and the consequences in terms of cost consciousness. Measurement instruments were based on those used in prior studies.
The results show that there is a significant relation between formal authority and the use of the AIS for decision management and decision control. The formal allocation of decision rights to physicians results in a significantly greater use of KPI by physicians in the management of clinical activities. However, the relation between formal authority and cost-consciousness is not significant. The reason why is that physician manager do not agree that KPI cannot reflect accurately the efficiency and productivity of their clinical unit. In addition, informal power has a negative impact on cost consciousness.
This study provides empirical evidence of the consequences on physician behavior due to the dual influences of formal and informal authority. The findings demonstrate the importance of implementing new accountability arrangements and KPI designed to encourage physicians to become effectively integrated in hospital management structures. It is only when KPI are designed and implemented to support physician managers that it is possible to create a culture in hospitals where the major stakeholders are committed to providing good quality care while at the same time maintaining financial viability. However, to improve the cost-consciousness, physician mangers need more information that KPI can positively reflect unit activity and productivity.

第一章 緒論 1
第一節 背景與動機 1
第二節 研究目的 3
(一) 健保與醫師主管的決策行為 3
(二) 專業規範與經營角色的衝突 4
(三) 財務預算系統與主管行為 4
(四) 財務預算資訊的決策支援效益 5
第三節 預期貢獻 6
第二章 文獻探討 8
第一節 探索醫療管理結構 8
(一) 管理的意義及重要性 8
(二) 醫院管理結構 9
第二節 醫療管理者與醫師管理者的工作內容 10
(一) 醫師主管的職責 10
(二) 組織內的權力來源與運作 11
(三) 權責的分派與正式職權 13
(四) 正式職權結構及財務預算資訊系統 13
(五) 非正式職權結構及財務預算資訊系統 14
(六) 醫院財務 16
(七) 決策控制與決策管理 18
(八) 成本意識與組織成果 20
第三節 現今醫務管理教育 21
第四節 財務預算資訊系統概述 23
(一) 資訊系統的控制 23
(二) 財務預算資訊系統的角色 24
(三) 財務預算資訊系統的設計特性 26
第三章 研究方法 27
第一節 研究架構和研究假說 28
（一）研究問題與概念性模型 29
（二）研究假說 30
第二節 研究設計和研究樣本 31
（一）研究設計 31
第三節 研究資材 32
（一）研究工具（研究問卷設計） 32
第四節 研究變項 （自變項、中介變項、依變項） 35
(一) 自變項 35
(二) 中介項 37
(三) 依變項 38
第五節 分析計畫：分析單位和分析方法（含模式建構） 39
(一) 描述性統計分析 39
(二) 因素分析 39
(三) 相關係數分析 39
(四) 單因子變異數分析 40
(五) 模式分析 40
第四章 研究結果 41
第一節 樣本結構分析 41
(一) 問卷回收率 41
(二) 研究樣本特性 43
第二節 統計資料分析 45
(一) 因素分析 45
(二) 相關係數分析 46
(三) 單因子變異數分析 47
(四) LISREL模式分析 51
第五章 討論與結論 55
第一節 研究討論 55
(一) 基本模式適配度分析 55
(二) 整體模式適配度分析 57
(三) 模式內在結構適配度分析 58
(四) 研究假說說明 59
(五) 路徑分析 60
第二節 研究結論 62
第三節 研究限制與未來研究方向 64
參考文獻 65
附錄一 問卷 71
附錄二 量表題項分析 79
附錄三 ANOVA 81
附錄四 L I S R E L 分析 86

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鄭中平（個人通訊，2006年4月23日）