為促進對國內長期照護中機構式照護的品質，本研究主要目的在探討國內的機構住民照顧品質，並進一步探討影響住民照顧結果之相關因素。研究架構主要參考Donabedian(1966)所提出的結構(structure)、過程(process)、結果(outcome)之品質管理理論模式，並探討機構的結構與過程二方面品質對照顧結果的影響。研究資料來自民國87-89年衛生署委託吳淑瓊教授主持之「機構式長期照護品質評估指標之建立」研究計畫，研究樣本包含十家護理之家及養護機構，由其中抽取297位住民，結果完成243位住民之評估，據以進行分析。研究資料係以外來專家評估機構整體品質，以該機構內護理人員來評估住民在前後三個月間共二次的健康情形的方式進行。
本研究最終目的是想瞭解住民在機構中得到的照顧結果，並希望檢驗機構結構面品質中的機構特質、工作人員組成、機構環境、機構住民組合等四個變項，及服務過程品質中的生活照顧服務、專業醫療照護服務、住民權益、管理程序、活動安排等五個變項對照顧結果品質之影響，又將住民因素放入分析模式中做為控制。照顧結果之測量包含：身體功能、失禁情形、認知功能、憂鬱症狀、意外事件、壓瘡及尿道感染等七項；將前四項歸為以住民為分析單位的住民功能改變結果，後三項歸為以機構為分析單位的機構照顧不良結果。
本研究除描述性分析外，另以雙變項分析來檢定機構結構與服務過程品質中各變項與照顧結果的關係，並以多變項分析來探討影響照顧結果的因素。研究結果如下：
1.本研究所選取機構中，在結構面品質以環境的舒適性的表現較差，如提供穩密環境及家庭化佈置等，在過程面品質則以住民權益的維護，如尊重住民隱私及自我決定權，及對住民的個別化管理程序，如住民約束及飲食規範表現較差。
2.以依變項照顧結果來看：在住民功能改變結果方面，在前後三個月間的變遷不多，生理功能變差的(46.1%)較變好的(27.6%)為多，精神功能變好的(38.3%)較變差的(26.7%)為多。在機構照顧不良結果中，各機構發生率分佈在0.07-0.24之間，十家機構的平均發生率為0.15，若與平均發生率做比較，高於及低於平均的各有五家機構。
3.在住民功能改變結果與各項因素的關係中，以t-檢定(t-test)及單因子變異數 (one-way ANOVA)分析後發現：機構大小、佔床率、住民數與病服員數比率、機構內住民插氣切管比率等四項與住民生理功能得分改變情形有顯著相關；但只有管理程序一項與住民精神功能得分改變情形有顯著相關。
4.在機構照顧不良結果與各項因素的關係中，以無母數檢定之曼-惠特尼U檢定(Mann-Whitney U test)及克-瓦二氏單因子等級變異數(Kruskal-Wallis)分析後發現：因機構數太少，並無任何因素呈現顯著相關，但結構面品質及過程面品質中，都有較大的相關性存在(0.05<p<0.5)；從其分佈的趨勢可發現，結構面因素中，住民數與病患服務員數的比率較低、專業人力資格符合項目較少、環境的安全性及舒適性表現較差、醫療設備的完整性較差的、住民完全依賴比率較低的，較易發生照顧不良的結果；過程面因素中，生活照顧及專業醫療照護服務表現較差的、管理程序表現較好的，較易發生不良照顧結果。
5.在多變項分析中，以線性複迴歸分析生理及精神功能改變二個模式，在置入相同變項，並控制其他因素之影響力後發現：
(1)生理功能變化迴歸模式之解釋力為14.8%，有多項結構面因素與生理功能變化有顯著相關(p<0.05)，其中機構體系為護理之家、機構床數較多的大型機構、住民數與護理人員人數比較多、專業人力資格較符合、機構環境的安全性較差、醫療設備完整性較差、機構內住民插鼻胃管的比率越高、住民身體功能完全依賴程度越嚴重的，住民生理功能越易變差。
(2)精神功能變化迴歸模式之解釋力為10.6%，並無任何變項與精神功能的改變有顯著相關，但有許多結構面因素中的變項與精神功能變化仍有較大差異性存在(0.05<p<0.5)，其中機構體系為養護機構的、床數越小的、住民數與病患服務員人數比率較大、機構內住民插鼻胃管的比率較大、住民性別為男性、子女數較少、疾病穩定度較差，住民精神功能較易變差、住民數與護理人員人數比率較小的，住民精神功能較易變差。
由本研究結果可知，機構在環境穩密性與家庭化佈置、對住民隱私及自我選擇權利的維護、及個別化管理的表現上仍有待加強，服務提供者應針對這幾方面再做努力。另外，研究結果也發現許多結構面品質都會對照顧結果有影響，可見目前機構設置標中對結構面品質的規範是很重要的，若要再放寬標準，便會對住民權益造成威脅，是絕不容許的。最後，也建議決策者可針對本研究結果中影響照顧結果的重要因素來加強評核，以保障機構內住民的權益與福利。

In order to improve the quality of care in long-term care (LTC) facilities in Taiwan, this study was aimed at investigating the care in domestic institutions, and to examine important factors which affect the outcome of care. The framework of the study is based on Donabedian’s (1966) quality management model, examining the institute for the influence of structural and process quality factors on the outcome of care. Data in this study are from the project “Development of Nursing Home Quality indicator in Taiwan”, 1998~2000, conducted by Doctor Shwu-Chong Wu. The survey was done in 10 long-term care facilities. There were 297 residents in the LTC facilities sampled, and the assessment of 243 residents was accomplished for further analysis. The data of the facility quality were from experts’ evaluation, and the data of health condition of the residents were collected by nurses in these facilities.
The purpose of the study is to realize the outcome of care received by the residents in LCT facilities, and to examine the factors which affect the outcome, including structure factors (facility character, the compose of workers in the facility, the facility environment, and the compose of residents), and process factors (the service of life care, the service of professional care, the right of the residents, the procedure of management, the arrangement of activities). Also, resident factors were put into the analysis model as control factors. The measure of the outcome includes 7 variables: physical function, incontinence, cognition function, depression symptoms, accidents events, bedsore and urinary infection. The first four variables can be generalized as the outcome of resident’s functional change, while the later three can be generalized as the outcome of poor care in the facilities.
In addition to the qualitative analysis, bivariate analysis is applied to examine the effect of the variables of structure and process on the outcome of care. Multiple variable analysis method is used to examine the factors in determining the outcome of care. The major findings are presented below:
1. For the quality of structure, the facilities selected in the study do not work well regarding environmental comfort, such as in providing private space and homelike decorates. As for the quality of process, the facilities do not work well in valuing rights of residents, such as privacy and self-decisions; neither in individual procedures of management, such as restrains and food.
2. In view of the variables which determine the outcome of care, the outcome of resident’s function does not change obviously during the three months: physical function deteriorated in 46.1% and improved in 27.6% of the samples, while mental function improved in 38.3% and deteriorated in 26.7% of the samples. The prevalence of outcome of poor care in the selected 10 facilities ranged between 0.07 and 0.24, with the mean value of 0.15. There were five facilities each with higher and lower prevalence than the mean value.
3. As for the relation between the outcome of residents’ functional change and factors of structural and process quality, from the results of t-test and one-way ANOVA analysis, it showed that the physical function of the residents changed with four variables, i.e. facility size, bed occupation, the ratio of resident and nurse aid, and the percentage of residents with the usage of trachea tubes in the facility. However, mental function changed with only one variable, i.e. the procedure of management.
4. The results of Mann-Whitney U test and Kruskal-Wallis analysis showed that no variables structural and process quality has significant effect on the outcome of poor management. However, the factors of structural and process quality are still related to the outcome of poor care in the facilities. The structural and process factors still exist some relations with the outcome of care(0.05<p<0.5).
5. The linear multiple regression method was applied to analyze residents’ functional change in both the physical and mental functions. The major results were showed below:
(1) The regression model of physical function change can explain 14.8% of the model. If the facility type is a nursing home, the facility size is larger, the ratio of residents to nurses is larger, the workers in the facility are more professional, the environment security is worse, or the percentage of dependent residents in the facility is lager, the physical function of the residents in the facility will deteriorate easier.
(2) The regression model of mental function change can explain 10.6% of the model, but no variable is significantly related to the change of mental function.
Our findings showed that the facilities in our study should strengthen themselves in environmental privacy, homelike decorates, the right of self-choice of the residents, and individual management. In addition, the result of our study showed that the outcome of care was indeed affected by the quality of structure. It is thus obvious that regulation on structural quality is very important in setting a LTC facility. Therefore, if we continue to make the standard even looser, the rights of these residents who live in the facility will be seriously threatened. Finally, in order to ensure the rights of the residents in LTC facilities, decision makers are strongly suggested to strengthen the evaluation on the facilities especially in the factors which affect substantially the outcome of care.

致謝 I
中文摘要 II
英文摘要 IV
目錄 VI
圖表目次 IX
第一章 前言 1
第一節 研究動機 1
第二節 機構品質的意涵與面向 2
第二章 文獻探討 3
第一節 機構照護品質的發展 3
第二節 機構品質的意涵與面向 5
(一)結構指標 6
(二)過程指標 7
(三)結果指標 7
第三節 機構品質指標 8
第四節 影響結果品質的因素 9
(一)結構面因素 9
1.機構特質 9
2.機構環境 10
3.工作人員組成 11
4.機構住民組成 11
(二)過程面因素 12
1.專業照護 12
2.一般照顧 12
3.機構管理程序 13
(三)住民因素 13
1.基本人口學 13
2.健康情形 14
第三章 研究方法 19
第一節 研究架構 19
第二節 研究假設 20
(一)機構結構面因素會影響住民的照顧結果 20
1. 住民的照顧結果會因機構特質不同而有差異 20
2. 住民的照顧結果會因機構的工作人員組成而有差異 20
3.住民的照顧結果會因機構環境不同而有差異 20
4.住民的照顧結果會因機構住民組合不同而有差異 20
(二)機構過程面因素會影響住民的照顧結果 21
第三節 研究對象 21
(一)研究機構 21
(二)研究樣本 21
第四節 研究工具 22
(一)問卷設計 22
1.文獻整理 22
2.深度訪談 22
3.焦點團體法 22
4.德菲法專家效度預測 22
(二)信效度測試 23
1.效度檢定 23
2.信度檢定 23
第五節 資料收集過程 23
第六節 研究變項 23
(一)結構面變項 24
(二)過程面變項 24
(三)住民特質變項 25
(四)照顧結果變項 26
第七節 資料分析方法 28
第四章 研究結果 47
第一節 資料回收情形 47
第二節 研究對象特性 48
(一)機構特性 48
1.機構結構特質 48
2.服務過程特質 49
(二)住民特性 50
1.基本人口學特質 50
2.入住時間 51
3.健康狀況 51
第三節 機構照顧的結果 51
(一)照顧結果之分布情形 52
1.功能改變的結果 52
(1)身體功能 52
(2)失禁情形 53
(3)認知功能 53
(4)憂鬱症狀 54
2.照顧不良的結果 54
(1)意外事件 54
(2)壓瘡情形 54
(3)尿道感染情形 55
(二)前後二次照顧結果的變遷情形 55
1.功能改變的結果 55
2.照顧不良的結果 55
第四節 住民功能改變的結果與機構結構、服務過程、
住民特質因素間的關係 56
(一)機構結構因素與功能改變結果的關係 56
(二)服務過程因素與功能改變結果的關係 58
(三)住民特質與住民功能改變結果的關係 59
第五節 照顧不良的結果與機構結構、服務過程的關係 60
(一)機構結構因素與照顧不良結果的關係 60
(二)服務過程與照顧不良結果的關係 60
第六節 住民健康改變結果與結構、過程因素，住民特質
之多變項關係 61
(一)機構結構、服務過程、住民特質與住民生理功能改變的關係 61
(二)機構結構、服務過程、住民特質與住民精神功能改變的關係 62
第五章 討論與建議 105
第一節 重要結果討論 105
(一)研究對象特性 105
(二)機構品質 105
1.機構結構品質 105
2.服務過程品質 106
3.照顧結果品質 106
(三)影響結果品質的因素 107
1.住民功能改變結果之影響因子 107
2.機構照顧不良結果之影響因子 109
第二節 研究限制 109
(一)研究對象之限制 109
(二)研究變項之限制 110
第三節 建議與應用 111
(一)研究上的建議 111
(二)研究結果之應用 111
第六章 參考文獻 113

(一) 中文部份
中華民國老人福利推動聯盟：老人安養護機構立案指南，1999。
內政部：老人福利法規彙編，1999。
內政部戶政司：近年我國老年人口數統計資料。內政部統計處，2002.4。
內政部統計處：中華民國八十九年臺閩地區老人狀況調查摘要分析。內政部統計處，2001。
王克捷、李慧菊合譯，James L. Heskett著：服務業的經營管理。台北：天下文化出版，1994。
行政院主計處：八十九年戶口及住宅普查統計資料。台北：行政院主計處，2000
行政院衛生署：衛生白皮書，1993。
吳淑瓊、徐慧娟、莊瑛智、張明正：功能評估在估計老人長期照護需要之應用。中華衛誌1996；15(6):533-45。
吳淑瓊、張明正：台灣老人的健康照護現況分析。台北市：台大公共衛生研究所暨衛生政策研究中心與台灣省家庭計畫研究所，1997。
林壽惠,劉達麗,吳玲娟,陳瑩琪,陳慈芳,劉藹宜,陳淑芬：護理之家成立一年半回顧座談會。護理雜誌1997;44(6):5-12.
胡月娟：罹患慢性病對病人的衝擊及其相關因素之探討。公共衛生雜誌1992;19 (2):207-221。
徐慧娟：長期照護結果品質評值─以護理之家院民評估量表(MDS)為例。護理雜誌1999;46(1):57-64。
張定昌譯，Deming, W. E.著：品質經營所需之變革。品質管制月刊1996;24(3):74-81。
許菁菁：臺北市安養中心照護品質之探討。台灣大學衛生政策管理研究所碩士論文，1994。
陳美女：護理之家照護品質調查之研究。中國醫藥學院醫務管理學研究所碩士論文，1994。
黃松林：老人養護機構服務提供與被養護者滿意程度之研究。東海大學社會工作研究所碩士論文，1994。
楊瑞珍、黃璉華、白璐、胡幼慧：自費安養機構老人的健康維護需求及其相關因素之探討。中華衛誌1995;14(6):477-485。
楊嘉玲：護理之家機構照護品質指標：以老年住民、家屬及護理人員的觀點探討。私立長庚大學護理學研究所碩士論文，1999。
葉莉莉、杜淑玲、溫敏杰、林憲、戴臆珊：台南市養護機構概況與住民生理、功能及心理社會狀態調查。新台北護理期刊2000;2(2):97-105。
鄭雪：基隆地區扶養機構老人健康狀況與生活照顧之探討。公共衛生1998;24(4):235-250。
戴玉慈、徐亞瑛、熊秉荃、陳月枝、黃久美：台北地區老人長期療養機構的環境調查。護理雜誌1992;39(2):45-54。
謝美娥：老人長期照護的相關議題。台北：桂冠，1993。
(二) 英文部份
Barbara I,Braun, PhD .The Effect of nursing home quality on patient outcome. Journal of the American Geriatrics Society1991;39(4): 329-338.
Cohen,J.w.,&Spetor,W. D. The effect of medicaid reimbursement on quality of care in nursing homes.Journal of Health Economics1996;15: 23-48.
Counsell, Steven R, Holder, Carolyn M, Liebenauer, Laura L. Palmer, Robert M, Fortinsky, Richard H, Kresevic, Denise M, Quinn, Linda M, Allen, Kyle R, Covinsky, Kenneth E, Landefeld C, Seth. Effects of multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital. Journal of the American Geriatrics Society. Dec 2000; 48(2):1572-81.
Davis, M. On nursing home quality: A review and analysis. Medical Care1991;48(2):129-166.
Dellefield, Mary Ellen. Relationship between nurse staffing in nursing homes and quality indicators: a literature review. Journal of Gerontological Nursing2000;26(6):14-28.
Ferrans, C., Powers, M. Psychometric assessment of the qualityof life index. Research in Nursing & Health1992;15:29-38.
Ferrans, C., Powers, M. Quality of life index: development and psychometric properties. Advances in Nursing Science1985; 8(1): 15-24.
Fiatarone, M. A., Marks, E. C., Ryan, N. D., Meredith, C. N., Lipsitz, L. A., &Evans,W. J. High intensity strength training in nonagenarians. Journal of the American Medical Association1990;253(22):3029-34.
Fisher,N. M., Pendergast, D. R., Calkins, E.Muscle rehabilitation in impaired elderly nursing home residents. Archives of Physical Medicine and Rehabilitation1991;72:181-185.
Fletcher, R. H., Malley, M. S., Earp, J., Littleon, T. A., Flecther, S. W., Greganti, M. A., Davidson R. A., and Taylor, J. Patients’ Priorities for Medical Care. Medical Care1983;2(1):234-242.
Fries BE, Morris JN, Skarupski KA,, Blaum CS, Galecki A, Bookstein F, Ribbe M. Accelerated dysfunction among the very oldest-old in nursing homes. Journals of Gerontology. Series A, Biological Sciences & Medical Sciences2000; 55(6):M336-41.
Garibaldi, R. A., Brodine, S., Matsumiya, S. Infections among patients in nursing homes. New England Journal of Medicine1981;305(15):731-35.
Garrard, J., Kane, R. L., Radosevich, D. M., Skay, C. L., Arnold, S.,Kepferle, L., Mcdermott,S., Buchanan, J. L. Impact of geriatric nurse practitioners on nursing-home residents’ functional status, satisfaction, and discharge outcomes. Medical Care1990;28:271-283.
Georgopoulos, B,Mann, F. The Community General Hospital. New York: Macmillan.1962.
Grant, N. K. ,Reimer, M., Bannatyne, J. Indicators of quality in long-term care facilities. Int. Nurs. Stand1996;33(5):467-478.
Grau,L., Chandler,B.,Saunders, C. Nursing home residents’ perceptions the quality of their care. Journal of Psychosocial Nursing1995;33(5):34-41.
Gustafson, D., Sainfort, F., Van Konigsveld, Zimmerman, D. The quality assessment index (QAI) for measuring nursing home quality. Health Services Research1990; 25(1):97-110.
Harrison, M. B., Juniper, E. F., Mitchell-DiCenso, A. Quality of life as an outcome in nursing research “may you have a long and healthy life”, Canadian Journal of Nursing Research1996;28(3):49-68.
Hegyvary ST, Haussman RK. Correlates of the quality of nursing care. Journal of Nursing Administration1976;6(9):22-7.
Hegyvary ST, Haussman RK. The relationship of nursing process and patient outcomes. Journal of Nursing Administration1976;6(9):18-21.
Hyde, Joan, Hillygus, Jennifer, Levy, Becca, Levkoff, Sue. Using outcome measures to provide excellence in Alzheimer care. American Journal of Alzheimer''s Disease1998;13(5):265-272.
Joanne,R.. The joyful road to restraint-free care. Oregan: Robert Wood Johnson Fundation.1991.
Kane, R. L., Garrard, J., Skay, C. L., Radosevich, D. M., Buchanan, J. L., Mcdermott, S. M., Arnold, S. B., Kepperie, L. Effect of a geriatric nurse practitioner on the process and outcomes of nursing home care. American Journal of Public Health1989;79:1271-77.
Kenia, M. C., Jack, L. M., and Mary, A P. Improving Service Through Patient Surveys in a Multihospital Organization. Hospital & Health Service Adminstration1986;24(9):76-80.
Lemke Sonne, Moos Rudolf H. Quality of residential settings for elderly adults. Journal of Gerontology1986; 41(2):268-276.
Lewis MA. Leake B. Clark V. Leal-Sotelo M. Case mix and outcomes of nursing home patients. The importance of prior nursing home care and admission from home versus hospital. Medical Care1989;27(4):376-85.
Linn MW, Gurel L, Linn BS. Patient outcomes as a measure of quality in nursing home care. Am J Public Health1977;67(4):337-344.
Linn MW, Gurel L, Williford WO, Overall J, Gurland B, Laughlin P, Barchiesi A. Nursing home care as an alternative to psychiatric hospitalization. A Veterans Administration cooperative study. Archives of General Psychiatry1985;42(6):544-51.
Linn, M.. A nursing home rating scale. Geriatrics1996;21(5):532-538.
Moos, R., Lemke, S.. Multiphasic environmental assessment procedure user’s guide. Palo Alto: Center for Health Care Evaluation, Department of Veterans Affairs and Stanford University Medical Centers. 1992
Moseley, C. B.The impact of restraints on nursing home resident outcomes. American Journal of Medical Quality1997;12(2):94-102.
Mukamel, D. B.Risk adjusted outcome measures and quality of care in nursing homes. Medical Care1997;35:367-385.
Mukamel, Dana B, Brower, Christine A. Influence of risk adjustment methods on conclusions about quality of care in nursing homes based on outcome measures. Gerontologist1998;38(6):695-703.
Mullins, L., Nelson, C., Busciglio, H., Weiner, H.. Job Satisfaction among nursing home personnel: The impact of organizational structure and supervisory power. The Journal of Long-Term Care Administration1988; Spring:12-17.
Murray AM, Levkoff SE, Wetle TT, Beckett L, Cleary PD, Schor JD, Lipsitz LA, Rowe JW, Evans DA. Acute delirium and functional decline in the hospitalized elderly patient. Journal of Gerontology1993; 48(5):M181-6.
Oleson, M.. Nursing home residents’ quality of life .1992.Doctoral dissertation, Rush University.
Parasuraman , A, V. A, Zeithaml and L. L. Berry. Communication and control process in the delivery of service quality. Journal of Marketing1988;52:35-48.
Parasuraman, A., Aeithaml, V., Berry, L. SERVQUAL: A multi item scale for measuring consumer perception of service quality. Journal of Retailing1998; 64(Spring):12-40.
Parasuraman, A., Zeithaml, V. A., and Berry, L. L. A Conceptual Model of Service Quality and Its Implication for Future Research. Journal of Marketing1985;49(Fall):41-50.
Patterson, B. J. The process of social support: adjusting to life in a nursing home. Journal of Advanced Nursing1995; 21: 682-89.
Porell, Frank W, Caro, Francis G, Silva, Ajith, Monane, Mark. University of Massachusetts at Boston. Gerontology Institute Longitudinal analysis of nursing home outcomes. 1997 :Gerontology Institute, University of Massachusetts Boston, Boston, MA.
Porell, Frank W, Caro, Francis G, Silva, Ajith. University of Massachusetts at Boston. Gerontology Institute Development of health outcome measures for nursing homes in Massachusetts: working paper. 1996:Gerontology Institute, University of Massachusetts Boston, Boston, MA.
Porell, Frank W. Caro, Francis G. University of Massachusetts at Boston. Gerontology Institute Facility-level outcome performance measures for nursing homes. 1997: Gerontology Institute, University of Massachusetts Boston, Boston, MA.
Pruchno RA, Rose MS. The effect of long-term care environments on health outcomes. Gerontologist2000; 40(4):422-8.
Przybylski BR, Dumont ED, Watkins ME, Warren SA, Beaulne AP, Lier DA. Outcomes of enhanced physical and occupational therapy service in a nursing home setting. Archives of Physical Medicine & Rehabilitation1996;77(6):554-61.
Rubenstein, L. Z., Robbins, A. S., josephson, K R., Schulman, B. L., Osterweil, D. The value of assessing falls in an elderly population. Annals of Internal Medicine1990;113:308-316.
Spector, W. D., Takada, H. A. Characteristics of nursing homes that affect resident outcomes. Journal of Aging and Health1991;3(4):427-454.
Spector, William D, Mukamel, Dana B. Using outcomes to make inferences about nursing home quality. Evaluation and the Health Professions1998;21(3):291-315.
Spector, William D, Selden, Thomas M, Cohen, Joel W. Impact of ownership type on nursing home outcomes. Health Economics1998;7:639-653.
Thapa PB, Brockman KG, Gideon P, Fought RL, Ray WA. Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances， incidence， and risk factors. Journal of the American Geriatrics Society1996; 44(3): 273-8.
Werley,H.H., Devine,E.C., Zorn, C. R., Ryan, P.,Westra,L. The nursing minimum data sets: Abstraction tool for standalized, comparable, essestial data. American Journal of Public Health1991;81(4):421-426.
Wieland D, Rubenstein LZ, Ouslander JG, Martin SE. Organizing an academic nursing home. Impacts on institutionalized elderly. JAMA1986;255(19):2622-7.
William D, Spector, Dana B. Mukamel. Using outcomes to make inferences about nursing home quality. AHCPR. Evaluation& The Health Profession1998; 21(3): 291-315.
Zimmerman, C. D. Quality: Key to Service Productivity. Quality Progress1985;June:32-35.