臺灣博碩士論文加值系統

隨著國內醫療產業環境的變化，醫院在面臨競爭日益激烈的生存壓力下，成本的分析與控制愈來愈受到重視，尤其在總額預算下，醫院間競爭的決勝關鍵將在於對品質的要求以及對成本的瞭解。而醫院經營最主要的目的之一，即在於提供病患住院之照護，因此，瞭解住院部門的資源耗用情形，將有助於拓展組織生存空間。由於在病患接受住院照護的過程中，除一般醫療診察、檢查、手術外，護理照護服務亦扮演著舉足輕重的角色，故使護理照護成本分析成為成本管理中不可或缺的一環。因此，本研究最主要的目的在於參考國外病人分類系統以及成本分析模式之發展，研擬一套結合診斷與住院病程之前瞻性成本分析模式，並利用研究所得之成本資訊，提供護理部門進行成本管理之參考。
本研究係參考Fischer（1998）所發展的多重面向分類模式之概念，將病人日依不同面向進行分類，並建構其分類矩陣模型，建立步驟分為三大階段，第一階段首先建立各項護理活動資源耗用模式，第二階段建立病人分類並進行成本分析，第三階段則利用第二組資料驗證所建立之成本分析模式。分析之樣本資料收集自個案醫院五個一般內外科病房，資料收集期間自92年2月至4月，經過初步分析後，利用18個診斷，132種病人日類別，共2,884病人日之資料進行模式之建立。
研究結果發現以診斷與住院病程兩面向分析病人日之平均資源耗用，不同診斷病程之病人日其護理照護成本不同；而各診斷病程日可依據資源耗用之模式分為16個相似的群組，當以第二組資料驗證模式之預測能力，總體樣本估計誤差為-0.34%，相較於其他研究，本研究整體預測能力相當準確。
本研究以結合診斷與住院病程為基礎之成本分析模式可提供護理部門進行成本管理以及護理人力之配置，並能結合病例組合之資訊，同時進行護理短、中、長期的人力資源規劃，滿足管理之需求。

With the continuously changing of medical industrial environment, hospitals in Taiwan face more and more fierce competition. Cost control and quality enhancement become the key factors in organization’s survival, especially when the global budget mechanism has been implemented. However, one of the major functions of hospitals is to provide inpatient services, which consume most of hospital resources. Understanding the resources utilization of hospitalization department will facilitate hospital to extend viability. In the process of providing patient care, nursing care plays a vital role as well as medical care, examination, and operation do. Nursing cost analysis therefore becomes an essential part of cost management. Thus, the purpose of this research is to develop a prototypical model of nursing care cost analysis which integrates diagnosis, patient day in order of stay, and resources utilization. Moreover, we wish to provide the useful information for nurse managers and support them to perform cost management efficiently.
The study adopts the concept of multiple dimensional classification model presented by Fischer (1998). In our model, we classify patient days into several groups by different dimensions and establish a patient day classification matrix. The establishing process was divided into three stages: 1. Develop resource consumption patterns for individual nursing care activities. 2. Establish patient day classification system and nursing care costing model. 3. Validate the nursing care costing model by the second set of data.
The data of cost and nursing care activities collected form five sample wards each patient day in a certain medical center from February to April in 2003 are analyzed in this study. We use 18 diagnoses and 132 patient day types from 2,884 patient days to build the final model.
The results of this research are as follows. When we classified the patient days into groups by these two dimensions of diagnosis and patient stay process, different resources utilization patterns are found. Each patient day can be classified into 16 clusters based on their resources utilization patterns. The overall estimation error is -0.34%. Comparing with earlier researches, predictability of our model is superior.
Through this study, it can be concluded that the nursing care costing model integrated diagnosis, patient day in order of stay, and resource utilization is applicable. Moreover, it can provide valuable information for nurse managers from the combining of case-mix not only for short- term cost control and nurse staffing but also for long-term human resource planning to meet the various management needs.

目錄
致謝 I
中文摘要 III
英文摘要 IV
目錄 V
圖目錄 VII
表目錄 X
第一章 緒論 1
第一節 研究緣起 1
第二節 研究目的 4
第二章 文獻探討 5
第一節 護理成本管理的重要性 5
第二節 護理成本之內涵及分類 8
第三節 護理成本分析方法 16
第四節 病人分類系統之內涵與發展 28
第五節 利用病人分類系統計算護理成本之應用 43
第三章 研究方法 54
第一節 研究設計 54
第二節 研究對象與資料收集 59
第三節 研究變項與操作型定義 63
第四節 資料處理與分析 67
第五節 研究假設與研究限制 71
第四章 研究結果 73
第一節 護理工作分析 73
第二節 資源耗用模式之建立 76
第三節 病人日護理活動時間分析 78
第四節 病人日分類之建立 82
第五節 病人日護理照護成本 85
第六節 成本分析模式之驗證 88
第五章 討論與結論 132
第一節 討論 132
第二節 結論與建議 145
參考文獻 147
中文部分 147
英文部分 148
附錄 158
附錄一 直接護理活動定義 158
附錄二 間接護理活動調查表 179
附錄三 直接護理活動勾選表 180
附錄四 集群過程 182
圖目錄
圖2-1 護理成本要素圖 10
圖2-2 每日病人護理資源耗用示意圖 17
圖2-3 RVUs成本流動示意圖 19
圖2-4 以病人嚴重度為基礎之成本流動示意圖 20
圖2-5 成本精確性與資料收集成本關係圖 21
圖2-6 以病人嚴重度為基礎計算DRG護理成本之成本流動示意圖 22
圖2-7 RIMs成本流動示意圖 25
圖2-8 病人分類系統要素圖 33
圖2-9 多面向病人分類矩陣 39
圖3-1 研究流程圖 54
圖3-2 研究架構圖 55
圖3-3 多重面向病人日分類矩陣模型示意圖 56
圖4-1 各病房佔床率 116
圖4-2 A病房直接護理時間總計 116
圖4-3 B病房直接護理時間總計 116
圖4-4 C病房直接護理時間總計 117
圖4-5 D病房直接護理時間總計 117
圖4-6 E病房直接護理時間總計 117
圖4-7 各病房間接護理時間總計 118
圖4-8 群集分析樹形圖 118
圖4-9 診斷碼070之資源耗用變動圖 119
圖4-10 診斷碼250之資源耗用變動圖 119
圖4-11 診斷碼413之資源耗用變動圖 119
圖4-12 診斷碼414之資源耗用變動圖 120
圖4-13 診斷碼427之資源耗用變動圖 120
圖4-14 診斷碼434之資源耗用變動圖 120
圖4-15 診斷碼456之資源耗用變動圖 121
圖4-16 診斷碼485之資源耗用變動圖 121
圖4-17 診斷碼531之資源耗用變動圖 121
圖4-18 診斷碼550之資源耗用變動圖 122
圖4-19 診斷碼571之資源耗用變動圖 122
圖4-20 診斷碼592之資源耗用變動圖 122
圖4-21 診斷碼599之資源耗用變動圖 123
圖4-22 診斷碼600之資源耗用變動圖 123
圖4-23 診斷碼715之資源耗用變動圖 123
圖4-24 診斷碼717之資源耗用變動圖 124
圖4-25 診斷碼733之資源耗用變動圖 124
圖4-26 診斷碼V54之資源耗用變動圖 124
圖4-27 診斷碼070成本變動圖 125
圖4-28 診斷碼250成本變動圖 125
圖4-29 診斷碼413成本變動圖 125
圖4-30 診斷碼414成本變動圖 126
圖4-31 診斷碼427成本變動圖 126
圖4-32 診斷碼434成本變動圖 126
圖4-33 診斷碼456成本變動圖 127
圖4-34 診斷碼485成本變動圖 127
圖4-35 診斷碼531成本變動圖 127
圖4-36 診斷碼550成本變動圖 128
圖4-37 診斷碼571成本變動圖 128
圖4-38 診斷碼592成本變動圖 128
圖4-39 診斷碼599成本變動圖 129
圖4-40 診斷碼600成本變動圖 129
圖4-41 診斷碼715成本變動圖 129
圖4-42 診斷碼717成本變動圖 130
圖4-43 診斷碼733成本變動圖 130
圖4-44 診斷碼V54成本變動圖 130
圖4-45 各診斷總合成本差異 131
圖4-46 各診斷平均每日成本差異 131
圖4-47 各病房合計成本差異 131
表目錄
表2-1 護理成本內涵與分類彙總表 14
表2-2 護理成本分析方法比較表 27
表3-1 取樣病房概況表 60
表3-2 間接護理時間耗用模式之變項說明 65
表3-3 建立病人分類之變項說明 66
表3-4 診斷與住院病程次數分配表 70
表4-1 工作時間、個人時間、上班時間分配表 91
表4-2 直接護理、間接護理、行政活動工作時間分配表 91
表4-3 間接護理活動時間分配表 92
表4-4 病房整日人力估計表 92
表4-5 直接護理活動平均標準工時 93
表4-6 直接護理活動耗材及設備成本表 94
表4-7 間接護理時間預測模式迴歸係數 94
表4-8 3月份病房概況表 95
表4-9 4月份病房概況表 95
表4-10 病房直接護理活動統計表 96
表4-11 病房間接護理活動時間統計表 96
表4-12 各病房平均每人日護理時間統計表 97
表4-13 樣本統計表 98
表4-14 第一組樣本各診斷病程日之平均資源耗用 99
表4-15 各群集之平均資源耗用 102
表4-16 各診斷病程日之資源耗用預測值 103
表4-17 排班護理人員人力成本與病房行政成本 105
表4-18 病房總設備成本 105
表4-19 各群集之病人日成本 105
表4-20 各診斷病程日之資源耗用成本 106
表4-21 第二組樣本各診斷病程日之平均資源耗用 109
表4-22 各診斷病程日之差異百分比 111
表4-23 各項資源耗用絕對差異之次數分配表 114
表4-24 各診斷之資源耗用差異百分比 114
表4-25 第二組樣本之各病房診斷次數分配表 115
表4-26 病房總成本差異百分比 115
表5-1 各項資源耗用絕對差異之次數分佈－樣本數大於10 144
表5-2 各項資源耗用變異係數之分佈 144
表5-3 各項資源耗用絕對差異之分佈－臨床路徑 144

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