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研究生:林秀萍
研究生(外文):Lin, Hsiu-Ping
論文名稱:千山響杜鵑:台灣精神科診所的發展
論文名稱(外文):Rebels Gone ‘Cuckoo’ with Institutional Causes: The Case of Taiwan’s Psychiatric Clinics
指導教授:洪世章洪世章引用關係
指導教授(外文):Hung, Shih-Chang
口試委員:林博文李傳楷張維安王耀德
口試委員(外文):Lin, Bou-WenLee, Chuan-KaiChang, Wei-AnWang, Yau-De
口試日期:2017-01-19
學位類別:博士
校院名稱:國立清華大學
系所名稱:科技管理研究所
學門:商業及管理學門
學類:其他商業及管理學類
論文種類:學術論文
論文出版年:2017
畢業學年度:105
語文別:中文
論文頁數:63
中文關鍵詞:制度創業精神醫療全民健康保險總額給付
外文關鍵詞:Institutional EntreprenurshipPsychiatric ClinicsNational Health InsuranceGlobal Budget
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在全民健保的總額預算支付制度影響下,台灣的各大醫院競相追逐規模經濟,醫院的各個醫療科別,都有明顯成長。在這大者恆大的普遍現象裡,精神科卻是一個例外;伴隨著大醫院裡精神科別發展的停滯,是各地基層精神醫療診所的蓬勃發展。本研究援引制度創業理論,採用質性的研究方法,來解釋精神科發展的異象,本文探究精神科場域樣貌的變遷,聚焦在三個研究問題以分析造成變遷的脈絡:精神診所為何興起?誰是促成精神科診所發展的制度創業家?以及這些制度創業家如何運用策略行動來改變場域?我們的研究指出,法規推力與市場拉力是造成原本任職醫院的精神科醫師出走的主要因素;在精神醫療場域之中,位於中間結構位置的醫師是精神科診所發展的制度創業家,他們採取了社群與協會的建構、資源的連結與引入、以及新活動的論述傳播等三種制度策略,創建新的制度場域。
Under the prevailing regulation of global budget payment, hospitals in Taiwan have been expanding in scale to increase market share. Consequently, the big hospitals get bigger, with their various medical departments growing in parallel. However, psychiatrics departments in hospitals have not expanded; instead, it is the number of psychiatric clinics that has been growing dramatically. Using qualitative research procedures, we draw on the institutional entrepreneurship perspective to explain this anomaly. We focus on three research questions: First, why have psychiatric clinics proliferated? Second, who were most likely to become institutional entrepreneurs leading changes in these psychiatric clinics? Third, what kind of strategies did the institutional entrepreneurs employ to deal with institutional pressures? Our findings show that the main factors that led psychiatrists to engage in entrepreneurial activity were ‘regulation-push force’ and ‘market-pull force’. The chiefs of psychiatric departments, and specifically those within regional hospitals, have a tendency to become leading institutional entrepreneurs. We also found that, in responding to institutional pressures, these entrepreneurs mainly deployed three strategies: the formation of associations and coalitions of various kinds; the drawing and linking of external resources, and the engagement with discursive and pedagogic practices.
目錄
Abstract II
目錄 V
圖目錄 VII
表目錄 VIII
第壹章、導論 1
第貳章、理論背景 3
第一節、制度理論 3
第二節、制度創業 4
第三節、制度創業的場域因素 5
第四節、制度創業的個體因素 6
第五節、制度策略與工作 7
第參章、研究方法 9
第一節、自然探究法 9
第二節、個案選取理由 9
第三節、資料來源 9
一、研究資料收集 9
二、資料與研究問題之關聯性 12
第四節、資料分析 12
第肆章、台灣精神醫療發展歷史的政治、社會與文化脈絡 13
第一節:日本殖民時期─從放任到安置(1895–1945年) 14
第二節:林宗義教授時期─從收容到醫療(1945–1955年) 17
第三節:精神醫療建立大型機構化時期─從小型到大型(1951-1966年) 20
第四節:精神醫療專業制度化時期─從各自發揮到制度建立(1968-1995年) 24
第五節、台灣醫療界的異象─從醫院到診所 28
一、政策扶持下的綜合醫院精神醫療 28
二、扶持政策取消後的綜合醫院精神醫療 29
第伍章、台灣精神科診所的制度化創業過程 32
第一節、精神醫療中基層診所為何興起? 33
一、法規推力 33
二、市場拉力 35
第二節、推動精神科基層診所興起的主要行動者是誰? 37
第三節、制度創業家的策略活動為何? 42
一、社群與協會的建構 42
二、資源的連結與引入 46
三、新活動的論述傳播 49
第陸章、討論 51
第一節、理論意涵 51
第二節、實務意涵 54
第柒章、結論與未來研究方向 55
參考文獻 57


圖目錄
圖1 大型醫院整體及精神科申報健保點數的變化 29
圖2 台灣歷年精神科診所數量 30
圖3 台灣基層診所與精神科診所成長率比較圖 31
圖4 精神科診所負責人開業前一職位統計 39



表目錄
表1 個人訪談受訪者身份分類 10
表2 日本殖民時間設立的精神病院及療養所 16
表3 精神醫療網各期推展重點 27
表4 精神醫療場域的改變 32
表5 台灣精神科診所的興起 32
表6 2005-2010年期間ATPC主要推動者之創業前職位調查 40
表7 ATPC佔台灣精神醫學會理監事席次 47
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