臺灣博碩士論文加值系統

總額預算實施之後，醫療院所的競爭更加激烈，只要是需要全民健保給付的科別，無一倖免，血液透析的治療也是如此。醫療院所的競爭不全是為了創造更大的利潤，有時甚至只是為了繼續生存下去。強化競爭力的策略有很多種，持續改善品質以達到病患要求越來越高的期待、控制成本、產品差異化或種類集中化、提高效率、增加客戶服務、創新、區隔目標市場、迎合病患需求的行銷組合，都是有效且改善主動權在自己的策略。不論哪一種策略，都是以客戶或目標市場的需求為中心。但病患對醫療服務品質的期待常與醫界的認知有落差，血液透析患者的特質和治療模式又有別於一般門診患者，且現代的價值觀也不同於過去，如何從患者需求的角度找出增加透析院所競爭力的方式，是個可以自我要求的簡單方法，也是本次研究的主要目的。在資源配置無法面面俱到的情況下，若能瞭解影響各類透析病人就醫決策的因素，則可將資源優先集中在病人最看重的項目上，使各透析院所的功能差異化並減少浪費；而且市場區隔化才能增加作業內容相近的透析院所互相合作，而非只有惡性競爭。
本次研究以臺北市與臺北縣的血液透析患者、家屬、醫護人員為研究對象，使用自擬的結構式、閉鎖式問卷進行隨機抽樣的問卷調查，問卷經過專家效度及信度的鑑定（Cronbach Coefficient Alpha：0.858）。所有的資料來源均是初級資料。發出問卷回收786份，回收663份，有效問卷共636份，有效問卷回收率約為81%。共有492位血液透析患者、48位陪病家屬、31位血液透析室內的醫師、及65位透析護理人員接受問卷調查。
研究發現透析患者平均年齡61歲，男女比例約為1：1，教育程度以小學最多，其次是大專（學）及高中（職）。無工作的人最多，將近八成的人目前無特定職業。已接受血液透析治療1~3年的人最多，其次是3~5年，絶大多數每週治療三次。與選擇透析院所的決策最有關係的患者人口學特質有三項：分別是「教育程度」、「交通工具」、「有無其他慢性疾病」。關於對原始考慮因素的重視程度，不論男女、不論哪一類的患者都是最重視透析過程中的醫療品質，也同樣都較不重視「是否免收取掛號費」、「收費高低」、「是否有接送服務」、「營養津貼(或免費便當飲料)」等項目。但經過因素分析萃取出七個共同因素後，全體患者對其重視程度依序為「醫療人員的效能」、「透析本身的表現品質」、「醫療照護的完整性」、「就醫費用」、「便利性」、「他人的滿意度」、「軟硬體資源的評價」。除此之外，會選擇醫院的患者比較在意透析設備的更新與進步，會選擇診所的患者比較在乎醫療服務的周延性與品質；會選擇公立醫院的患者比較在意透析設備的更新與相信公立醫院對耗材的更新，會選擇私立院所的患者需要的是個人化的醫療，能方便就醫且所求診的院所多半是慕名而至或是有醫護專業人員的介紹，需要已有初步的信任基礎。至於「是否交通方便」，只在患者重視程度排名的居中而已，反而是醫護人員過度在乎這個項目的影響力。不管何種立場，透析本身的醫療品質都是最被重視的。透析患者與一般民眾一樣都很重視醫師的醫術及醫護人員的服務態度。
雖然血液透析治療的技術多已標準化且知識也已相當成熟，但患者對醫術的重視程度仍排名在醫護人員的服務態度之前，顯見工作人員的服務態度固然重要，但加強專業的本質學能才是更重要的，空有親切花俏的服務態度而無專業能力的提昇，是無法爭取臺北都會區透析患者認同的。其他各種招攬病人的行銷手法對於相當理性的臺北都會區透析患者，都只是錦上添花，影響不大。

The competition between medical facilities became more intense after global budget. Every special section under the health insurance reimbursement were all in the storm, including hemodialysis. The competition with other medical facilities was not only for a profit but also for a simple purpose of survival. Many strategies of increasing competitiveness had been suggested, such as continuous improvement of quality, cost leadership, product differentiation, product focus, efficiency management, emphasizing customer service, innovation, searching target market, and developing a marketing mix from customers need. All of the above strategies were effective and could be controlled by oneself. However, all of the above strategies must be based on the need of customes. Unfortunately, the expectations of patients usually differed from the recognition of medical specialists on the topic of medical quality. The characteristic of patients on hemodialysis was also different from that of patients calling for general outpatient department. The values also changed from day to day. It is an important and simple method to find out the strategy to increase the competitiveness of dialysis facilities from the viewpoint of the needs of patients. It is also our aims to design this study. After the factors affecting the decision of selecting facilities in hemodialysis patients are figured out, the limited resourced can be focused on the items which patients considered as the most important. Then the style and function of the facility will be differentiated from those of others and the cost can be reduced. The market segmentation and the following concentration approach allow a facility to specialize and focus all its efforts on the special market segment. These accelerate cooperation between hemodialysis facilities and reduce the risk of vicious competition.
The patients, family members, doctors, and nurses in Taipei city and county were investigated with a structured, closed and self-designed questionnaire, which was confirmed by specialist validity and Kuder-Richardson reliability（Cronbach Coefficient Alpha: 0.858）. The samples were collected randomly and all these data were primary. Total 786 questionnaires were delivered, and 663 questionnaires were retrieved. Only 636 questionnaires were effective and the effective data collection rate was 81%. There were 492 patients, 48 family members, 31 doctors, and 65 nurses totally.
The result revealed that dialysis patients were older with an average age of 61 years and half the patients were male. The most had a level of elementary school education, following by junior collage and senior high school. About 80% were jobless. The most dialysis age was 1~3 years and the following was 3~5 years. The frequency of hemodialysis was thrice per week mostly. The strongest demographic factors affecting the decision of selecting facilities were the level of education, conveyance, and the presence of other chronic diseases. Whoever put the strongest emphasis on the performance quality of dialysis and the least emphasis on the “free of registry fee”, “expense”,“connecting service by conveyance of facilities”, and“nutrition allowance from facilities”. Factor analysis extracted seven common factors from these 33 consideration factors and their priority were as follows：“efficacy of medical personnel”, “Performance quality of dialysis”, “comprehensiveness of healthcare services”, “cost of seeking care”, “access”, “satisfaction of others”, “value of resources”. The importance of “traffic convenience”was fair from viewpoint of patients, but it was over-emphasis from the viewpoint of medical personnel. However, dialysis patients as well as the general patients paid much attention to medical skills of doctors, and the service attitude of medical personnel.
Although the treatment of hemodialysis was almost standardized and mature, patients still considered medical skills before the service attitude. It was apparent that reinforcement of medical skills was a top priority even though the service attitude was also very important. No dialysis patients will be attracted by means of perfect service attitude without reinforcement of medical skills in Taipei city and county. All other marketing methods contribute little to dialysis facilities for so rational patients.

口試委員會審定書…………………………………………………… i
誌謝…………………………………………………………………… ii
中文摘要……………………………………………………………… iii
英文摘要……………………………………………………………… v
目錄………………………………………………………………… viii
圖目錄………………………………………………………………… xi
表目錄………………………………………………………………… xii
第一章 緒論……………………………………………………… 1
第一節 研究背景………………………………………………… 1
第二節 研究動機………………………………………………… 4
第三節 研究目的………………………………………………… 7
第二章 文獻探討………………………………………………… 8
第一節 血液透析治療簡介及現況……………………………… 8
第二節 整體血液透析照護的需求與含義………………………10
第三節 醫療產業的競爭策略……………………………………12
第四節 影響病患選擇就醫院所的因素…………………………16
第五節 文獻綜合討論……………………………………………20
第三章 研究方法…………………………………………………22
第一節 研究設計…………………………………………………22
第二節 研究架構…………………………………………………23
第三節 研究假說…………………………………………………25
第四節 資料來源與材料…………………………………………27
第五節 研究變項…………………………………………………29
第六節 資料處理與分析方法……………………………………31
第四章 研究結果……………………………………………………33
第一節 人口學特質分析…………………………………………33
1.1 全體受訪者概觀…………………………………………33
1.2 患者特質分析……………………………………………33
第二節 選擇透析院所的考慮因素之分析………………………54
2.1 患者考量因素的綜合分析……………………………… 54
2.2 患者考量因素的因素分析……………………………… 70
2.3 患者、家屬、及醫護人員考量因素的比較…………… 75
第三節 透析醫療機構服務項目之分析…………………………81
第五章 討論…………………………………………………………85
第一節 人口學特質對選擇就醫院所的影響……………………85
第二節 考慮因素對選擇就醫院所的影響………………………90
第三節 因素分析結果之探討……………………………………95
第六章 結論與建議…………………………………………………99
第一節 結論………………………………………………………99
第二節 建議…………………………………………………… 102
參考文獻………………………………………………………………104
附錄……………………………………………………………………109

一、中文文獻
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